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THE  TREATMENT 


OF 


FRACTURES 


BY 

CHARLES  LOCKE  SCUDDER,  M.D. 

ASSISTANT   IX    CLINICAL   AND    OPERATIVE    SURGERY,    HARVARD    UNIVERSITY   MEDICAL   SCHOOL 
SURGEON    TO    THE   OUT-PATIENT    DEPARTMENT,  MASSACHUSETTS    GENERAL    HOSPITAL 


ITbirt)  lEMtion,  ITborouobl^  IRevise^ 


TRUitb  645  11  [lustrations 


PHILADELPHIA   AND   LONDON 

W.    B.    SAUNDERS    &    COMPANY 
1902 


^1)  l^f 

l<\0 


Copyright,  igoo,  bj'  W.  B.  Saunders 


Copyright,  igoi,  by  W.  B.  Saunders  &  Company 


Copyright,  1902,  by  W.  B.  Saunders  &  Company 


Registered  at  Stationers'  Hall,  London,  England 


TO 
ARTHUR  TRACY  CABOT,  A.M.,  M.D. 


PREFACE  TO  THE  THIRD  EDITION 


In  this  edition  several  new  but  not  uncommon  fractures  are 
described.  A  chapter  on  gunshot  fractures  of  the  long  bones 
is  added.  A  careful  review  of  the  reports  of  surgeons  in  the 
field  during  recent  wars,  together  with  the  ver}^  great  assistance 
afforded  by  Mr.  ]\Iakins'  valuable  systematic  contribution  to 
gunshot  fracttues — "Surgical  Experiences  in  South  Africa," — has 
made  it  possible  to  present  concisely  important  facts  regarding 
fractures  of  bone  produced  by  the  small-caliber  bullet.  Through 
the  courtesy  of  Mr.  Makins  and  his  publishers  I  am  able  to  illus- 
trate this  chapter  with  satisfactory-  plates.  The  general  text  of 
the  book  has  been  carefully  reviewed.  A  carefully  prepared 
index  is  added. 

I  wish  to  thank  Drs.  Putnam,  AValton,  Bullard,  and  Paul  for 
reviewing  the  chapters  upon  fractures  of  the  Skull  and  Spine. 
Photographs  are  introduced  in  place  of  many  of  the  drawings. 
The  uses  of  plaster-of- Paris  as  a  splint  material  are  more  fully 
illustrated. 

The  kindness  and  liberality  of  the  publishers  have  again  en- 
abled me  to  enhance  the  value  of  the  book  through  freedom  of 
illustration. 

Charles  L.  Scudder 

Boston,  Mass.,  August,  igo2 


PREFACE  TO  THE  FIRST  EDITION 


The  general  employment  of  anesthesia  in  the  examination 
and  the  initial  treatment  of  fractures,  especially  of  those  near  or 
involving  joints,  has  made  diagnosis  more  accurate  and  treat- 
ment more  intelligent.  The  application  of  the  Rontgen  ray  to 
the  diagnosis  of  fracture  of  bone  has  already  contributed  much 
toward  an  accurate  interpretation  of  the  physical  signs  of  frac- 
ture. This  greater  certainty  in  diagnosis  has  suggested  more 
direct  and  simpler  methods  of  treatment.  Antisepsis  has  opened 
to  operative  surgers'  a  vers'  profitable  field  in  the  treatment  of 
fractures.  The  final  results  after  the  open  incision  of  closed 
fractures  emphasize  the  fact  that  anesthesia,  antisepsis,  and  the 
Rontgen  ray  are  making  the  knowledge  of  fractures  more  exact, 
and  their  treatment  less  complicated.  The  attention  of  the  stu- 
dent is  diverted  from  theories  and  apparatus  to  the  actual  condi- 
tions that  exist  in  the  fractured  bone,  and  he  is  encouraged  to 
determine  for  himself  how  to  meet  the  conditions  found  in  each 
individual  case  of  fracture. 

This  book  is  intended  to  serve  as  a  guide  to  the  practitioner 
and  student  in  the  treatment  of  fractures  of  bone.  In  the  follow- 
ing pages  many  of  the  details  in  the  treatment  of  fractures  are 
described.  So  far  as  possible  these  details  are  illustrated.  A 
few  vers"  unusual  fractures  are  omitted.  Mechanical  simplicit}^ 
is  advocated.  An  exact  knowledge  of  anatomy  combined  with 
accurate  observation  is  recognized  as  the  proper  basis  for  the 
diagnosis  and  treatment  of  fractures.  The  expressions  "closed" 
and  "open"  fracture  are  used  in  place  of  "simple"  and  "com- 
pound" fracture.  "Closed"  and  "open"  express  definite  condi- 
tions, referring  to  the  freedom  from,  or  liability  to,  bacterial  infec- 
tion. The  old  expressions  are  misleading  despite  their  long 
usage.     Theories    of    treatment    are    not    discussed.     Types    of 


12  PREFACE 

dressings  for  special  fractures  are  described.  Many  illustrative 
clinical  cases  are  omitted  purposely. 

The  tracings  of  tlie  Rontgen  rays,  which  have  been  ver}^ 
generally  used  to  illustrate  the  sites  and  the  displacements  of 
fractures,  have  been  the  subject  of  careful  study.  Each  tracing 
represents  the  combined  interpretation  of  the  plate  made  by 
skilled  observers  who  were  in  every  instance  familiar  with  the 
clinical  aspects  of  the  case.  The  writings  of  many  who  have 
contributed  their  experience  to  the  literature  of  fractures  have 
been  consulted.  Those  to  whom  I  feel  indebted  for  suggestions 
are  mentioned  in  the  section  on  Bibliography.  References  to 
literature  are  not  made  in  the  text. 

I  take  this  opportunity  to  extend  my  thanks  to  the  members 
of  the  Surgical  Staff  of  the  Massachusetts  General  Hospital  for 
their  courtesy  in  permitting  me  to  study  cases  of  fracture  of  the 
lower  extremity  in  the  wards  of  the  hospital,  and  to  Professor 
Thomas  Dwight  for  the  use  of  valuable  anatomical  material.  I 
also  thank  Dr.  F.  J.  Cotton  for  an  untiring  interest  in  the  pro- 
duction of  most  of  the  drawings,  and  in  the  search  for  fracture 
literature.  The  half-tones  are  made  from  photographs  taken 
under  the  direct  superintendence  of  the  author.  Due  credit  for 
illustrations  not  original  is  given  next  the  legend. 

I  wish  to  thank  Mr.  Walter  Dodd  for  his  courtesy  and  interest 
connected  with  the  production  of  the  Rontgen-ray  plates,  and 
Dr.  H.  P.  Mosher  for  kind  assistance. 

The  chapter  on  the  Rontgen  ray  is  written  by  Dr.  E.  A.  Codman. 

Charles  T.  Scudder 

189  Beacon  Street,  Boston,  Mass. 
April,   igoo 


TABLE   OF   CONTENTS 


CHAPTER  I  ^''^^ 

Fractures  op  the  Skull ^' 

Fractures  of  the  Vault 24 

Fractures  of  the  Base 26 

Treatment ^'^ 

Later  Results  of  Fracture  of  the  Skull 38 

CHAPTER  II 

Fractures  of  the  Nasal  Bones 44 

The  Nasal  Septum 47 

"treatment 49 

Fractures  of  the  Malar  Bone 52 

Treatment ^^ 

Fracture  of  the  Superior  Maxilla 56 

Treatment 57 

Fractures  of  the  Inferior  Maxilla 59 

Treatment ^^ 

CHAPTER  III 

Fractures  of  the  Vertebr.^ 72 

Treatment ^^ 

CHAPTER  IV 

Fractures  of  the  Ribs ^4 

CHAPTER  V 

Fractures  of  the  Sternum 1^^ 

CHAPTER  VI 

Fractures  of  the  Pelvis ^^2 

Treatment ^^5 

Rupture  of  the  Urethra ^0' 

Rupture  of  the  Urinary  Bladder 1^8 

CHAPTER  VII 

Fractures  of  the  Clavicle ^  ^^ 

Treatment  in  Adults ^  ^^ 

Treatment  in  Children ^  ^ ' 

Operative  Treatment -^20 

i^ 


14  TABLE   OP   CONTENTS 

CHAPTER  VIII  PAGE 

Fractures  op  the  Scapula 12 1 

Treatment 123 


CHAPTER  IX 

Fractures  of  the  Humerus 125 

Fractures  of  the  Upper  End  of  the  Humerus 125 

Diagnosis 129 

Treatment 140 

Fracture  of  the  Upper  End  of  the  Humerus  with  a  Dislocation  of  the 

Upper  Fragment 145 

Fractures  of  the  Shaft  of  the  Humerus 147 

Fractures  of  the  Shaft  with  Little  Displacement 151 

Fractures  of  the  Shaft  with  Considerable  Displacement 156 

Fractures  of  the  Shaft  in  the  New-born 158 

The  Musculospiral  Nerve  in  Fracture  of  the  Humerus 159 

Malignant  Disease  Associated  with  Fracture  of  Bone 162 

Fractures  of  the  Elbow 162 

Diagnosis ■. 169 

Treatment 181 


CHAPTER  X 

Fractures  of  the  Bones  op  the  Forearm 192 

Fractures  of  Both  Radius  and  Ulna 192 

Treatment 201 

Nonunion  of  Fractures 212 

Fractures  of  the  Olecranon 214 

Treatment 217 

Tetanus 223 

Colles'  Fracture 223 

Diagnosis 23 1 

Treatment 236 

CHAPTER  XI 

Fractures  of  the  Carpus,  Metacarpus,  and  Phalanges 246 

Fractures  of  the  Carpus 246 

Fractures  of  the  Metacarpus 249 

Fractures  of  the  Phalanges 257 

Open  Fractures  of  the  Phalanges 259 


CHAPTER  XII 

Fractures  of  the  Femur 260 

Fracture  of  the  Hip  or  Neck  of  the  Femur 260 

Treatment 269 

Operative  Treatment . 277 

Fracture  of  the  Neck  of  the  Femur  in  Childhood 277 


TABLE   OF   CONTENTS  15 


l>AGli 


Fracture  of  the  Sliajt  oj  the  I'cmur 280 

Treatment ^^^ 

Subtrochanteric  Fracture  of  the  Femur 299 

Supracondyloid  Fracture  of  the  Femur 300 

Ambulatory  Treatment  of  Fracture  of  the  Thigh 303 

Fracture  of  the  Thigh  in  Childhood 309 

Separation  of  the  Lower  Epiphysis  of  the  Femur 314 

Treatment -^^^ 

Traumatic  Gangrene ^- ' 

321 
Septicemia 

Malignant  Edema ~^-  ^ 

Fat   Embolism ^ 

-CHAPTER  XIII 

Fractures  of  the  Patella 324 

Treatment ^^^ 

Open  Fracture  of  the  Patella 338 

Operation  in  Recent  Closed  Fractures  of  the  Patella 342 

CHAPTER  XIV 

Fractures  of  the  Leg ^■^" 

Treatment ^^^ 

Fractures  with  Little  or  No  Displacement 357 

Fractures  with  Considerable  Immediate  SweUing 3o9 

Fractures  Difficult  to  Hold  Reduced.  . , 37^0 

Treatment  of  Open  Fractures  of  the  Leg 3/4 

Thrombosis  and  Embolism 383 

Pott's  Fracture 

Treatment ^^^ 

Open  Pott's  Fracture -^"^^ 

CHAPTER  XV 

Fr.\ctures  of  the  Boxes  of  the  Foot -^OO 

Fracture  of  the  Astragalus ^^^ 

Open  Fracture  of  the  Astragalus  and  Os  Calcis 404 

Fracture  of  the  Metatarsal  Bones 405 

Fracture  of  the  Phalanges 


CHAPTER  XVI 
Anatomical  Facts  Regarding  the  Epiphyses 407 

CHAPTER  XVII 

Gunshot  Fractures  of  Bone 413 

Treatment 


1 6  TABLE   OF   CONTENTS 

CHAPTER  XVIII  PAGE 

The  Rontgen  Ray  and  Its  Relation  to  Fractures 425 

By  E.  a.  Codman,  M.D. 

CHAPTER  XIX 
The  Employment  of  Plaster-of-Paris ■ 441 

CHAPTER  XX 
The  Ambulatory  Treatment  of  Fractures 462 


BIBEIOGRAPHY 471 

INDEX 475 


THE 

Treatment  of  Fractures 


CHAPTER  I 
FRACTURES  OF  THE  SKULL 

It  is  unwise  to  consider  the  treatment  of  fracture  of  the  skull 
apart  from  a  more  or  less  systematic  review  of  traumatic  lesion  of 
the  brain. 

The  skull  is  the  brain's  protection.  In  cases  of  fracture  of  the 
skull  the  injur\'  to  the  brain  is  of  paramount  importance.  The 
immediate  damage  to  the  brain  may  be  caused  by  direct  pressure 
of  bony  fragments,  b}"  pressure  due  to  hemorrhage  from  torn 
vessels  within  the  skull,  by  bruising  of  the  brain  itself,  or  by  cere- 
bral edema.  Great  interest  attaches  to  serious  head-injuries,  not 
only  because  the  brain  may  be  damaged,  but  more  especially  be- 
cause the  lesions  are  often  obscured  by  an  intact  scalp.  A  proper 
determination  of  the  conditions  existing  after  a  given  head- 
accident  necessitates  careful  observation  of  symptoms,  com- 
bined wdth  good  judgment  in  interpreting  the  signs  present. 

Concussion  and  Contusion  of  the  Brain. — A  concussion  and 
a  contusion  of  the  brain  associated  with  minute  bruising  of  brain- 
tissue  wall  exist  after  all  serious  injuries  to  the  skull. 

The  symptoms  of  concussion  are  varied  according  to  the  sever- 
ity of  the  injury.  Following  slight  concussion,  the  individual  is 
stunned  by  the  accident ;  there  is  simple  vertigo,  possibly  mental 
confusion  lasting  but  a  short  time.  xVfter  severe  concussion  there 
will  follow  a  momentary  loss  of  consciousness,  or  there  may  be 

unconsciousness  of  longer  duration.    Vomiting  may  occur.    Head- 
2  17 


1 8  FRACTURES    OF   THE    SKULL 

ache  will  probably  be  present.  Following  a  still  more  severe  con- 
cussion, the  patient  will  be  profoundl}'  unconscious  for  a  long 
period.  The  sphincters  may  be  relaxed;  hence  involuntary 
micturition  and  defecation  will  occur  when  the  bladder  and  rec- 
tum become  overdistended.  Retention  of  urine  and  feces  is  the 
sign  immediately  after  the  injury.  Incontinence  is  the  evidence  of 
overdistention  of  the  viscus  in  these  cases.  The  pulse  will  become 
feeble  and  slow  along  with  the  general  systemic  depression.  The 
pupils  still  react  to  light.  The  temperature  will  be  subnormal. 
It  is  impossible  clinically  to  distinguish  between  concussion  and 
contusion  of  the  brain.  The  pathological  differences  are  more 
or  less  artificial. 

Laceration  of  the  Brain. — If  there  is  laceration  of  the  brain, 
the  symptoms  of  concussion  will  be  present  to  a  marked  degree, 
and  will  be  characterized  by  immediate,  pronounced,  and  long- 
continued  unconsciousness.  After  recovery  from  the  initial  shock 
of  the  accident  fever  will  be  present,  which  may  rise  to  103°  or 
104°  F.  Concussion  alone  is  never  associated  with  feverishness. 
Early  fever  is  a  sign  of  laceration.  Mental  irritability  and  rest- 
lessness will  mark  returning  consciousness.  If  the  motor  areas 
of  the  brain  are  involved,  signs  of  irritation  will  appear — 
namely,  muscular  twitchings  and  spasms  according  to  the  motor 
centers  imphcated. 

Compression  of  the  Brain. — Slight  hemorrhages  do  not  cause 
symptoms  of  compression;  neither  do  slight  depressions  of  the 
cranial  bones.  Before  symptoms  of  compression  appear,  the 
cranial  contents  must  be  impinged  upon  to  a  very  considerable  ex- 
tent. If  the  compression  is  sudden  and  limited,  there  is  an  irri- 
tation of  the  parts  involved,  which  is  manifested  by  restlessness 
and  delirium  and  by  twitching  of  certain  groups  of  muscles;  the 
pulse  is  hard  and  jiow;  If  the  compression  is  gradual,  whether 
it  be  localized  or  diffused,  the  brain  accommodates  itself  for  some 
time  to  the  new  conditions;,  the  appearance  of  the  symptoms  of 
local  pressure  is  delayed,  although  they  may  be  relatively  sudden 
in  their  onset.  Following  the  muscular  spasms  and  twitchings 
due  to  the  sudden  onset  of  pressure  there  may  appear  symptoms 
of  paresis  and  paralysis.  Loss  of  power  in  the  face  or  arm  or  leg 
indicates  a  lesion  about  the  fissure  of  Rolando,  upon  the  opposite 


EXTRADURAL  HGMORRHAGK 


19 


side.  Loss  of  power,  for  example,  in  the  right  arm  and  right  leg 
indicates  that  the  brain  lesion  is  about  the  fissure  of  Rolando  upon 
the  left  side  of  the  brain.  TMhrre  h  pressure  upon  the  third 
nerve  at  the  base  of  the  skuJL_dilatatjon_of  the  pupil  upon 
the  side  opposite  to  the  pressure  will  be  noticed.  This  pupil 
\viir  not  react  to  TTghY.  As  the  pressure  of  the  hemorrhage 
increases,  the  symptoms  will  again  become  more  general; 
convulsive  movements  of  the  limbs  and  body  appear,  and  the 
drowsiness  or  stupor  increases  to  profound  unconsciousness;  the 
pulse   becomes  rapid   and  small;  and  the   respiration  frequent, 


Fig.  I. — Fracture  of  skull  with  middle 
meningeal  hemorrhage.  Compression  of 
brain  by  blood. 


Fig.  2.— Fracture  of  skull  with  de- 
pressed fragments.  Compression  of  brain 
bv  bone. 


shallow,  and  sighing,  or  it  passes  into  stertor  and  Cheyne-Stokes' 
breathing  as  the  condition  becomes  immediately  grave;  the  tem- 
perature rises  high.  Focal  symptoms  may  exist  from  pressure 
by  bone  or  blood-clot,  apart  from  loss  of  consciousness. 

Extradural  Hemorrhage  (see  Figs,  i,  2).— A  most  important 
symptom  of  intracranial  hemorrhage  is  the  inter\-al  of  conscious- 
ness that  exists  from  the  time  of  the  injun,'  to  the  onset  of  uncon- 
sciousness. This  period  of  consciousness  ma}'  be  preceded  by  the 
temporary-  or  prolonged  unconsciousness  of  concussion.  Uncon- 
sciousness in  cases  of  intracranial  hemorrhage  is  due  to  an  increase 


20 


FRACTURES    OF   THE    SKULL 


of  the  intracranial  pressure  caused  b}'  the  presence  of  free  blood. 
An  interval  of  consciousness  exists  in  these  instances  in  from  one- 
half  to  two-thirds  of  all  cases.  In  the  cases  of  hemorrhage  which 
occur  without  an  interval  of  consciousness  (unconsciousness  com- 
ing on  immediately  upon  the  receipt  of  the  injury)  it  must  be  that 
the  injury  is  so  severe  that  the  unconsciousness  caused  by  the  con- 
cussion and  laceration  of  the  brain  is  continuous  with  the  uncon- 
sciousness from  hemorrhage.  The  unconsciousness  of  concussion 
is  continued  over  into  the  coma  of  compression.  The  duration  of 
the  interval  of  consciousness  may  vary  within  very  wide  limits; 
it  may  be  a  few  moments,  it  may  be  three  months. 


fiujituTe  on  larger  scale; 

jilaek  bristle  in  lumett. 

of  artery- 


Fig.  3. — Frontal  section  of  skull. 
Middle  meningeal  hemorrhage.  The 
dura  bulges  inward  toward  skull  cavity 
(diagram). 


Fig.  4. — A  case  of  rupture  of  middle  men- 
ingeal artery.  Preparation  of  dura  viewed 
from  outer  side  (Warren  Museum). 


The  sources  of  intracranial  hemorrhage,  whether  from  the  mid- 
dle meningeal  artery  (see  Fig.  3)  or  its  branches  (see  Fig.  4),  from 
the  middle  cerebral  arteries,  from  the  veins  of  the  pia  mater,  from 
the  sinuses  of  the  brain,  or  from  lacerated  brain-tissue,  can  not  be 
easily  differentiated  short  of  operative  procedure.  There  is  one 
condition  which  is  not  to  be  overlooked  in  connection  with  the 
question  of  hemorrhage — namely,  the  period  of  semiconsciousness 
which  sometimes  follows  concussion  and  laceration,  and  gives  rise 
to  the  suspicion  of  some  more  serious  gross  lesion.  To  illustrate : 
A  young  girl  received  a  severe  blow  upon  the  head.     A  true  period 


SUBARACHNOID    SEROUS    EXUDATION  2  1 

of  unconsciousness  followed.  There  were  no  external  evidences 
of  hemorrhage.  Convulsive  movements,  deviation  of  the  eyes, 
and  disturbance  of  the  pupils  were  absent.  The  breathing  was 
regular  and  of  normal  character.  Notwithstanding  the  absence 
of  other  untoward  symptoms,  complete  consciousness  did  not 
return  for  a  number  of  days  or  even  of  weeks.  In  such  a  case, 
after  a  number  of  days  the  question  naturally  presents  itself, 
Have  we  not  to  do  with  a  hemorrhage,  and  should  not  trephining 
be  considered?  The  absence  of  all  symptoms  excepting  the  un- 
consciousness should  lead  to  the  suspicion  that  we  have  to  do  with 
a  mental  state  rather  than  with  a  gross  lesion.  Hysteroid  semi- 
consciousness  (Walton)'  supervening  upon  a  blow  is  not  to  be 


Fig.  5. — Splintering  of  inner  table;  cross-sections;  diagrammatic:  a.  Usual  form  ot 
punctate  fracture  ;  d,  shows  that  a  linear  fracture  may  be  much  more  extensive  internally 
than  externally. 


mistaken    for    the    deepening    unconsciousness    which    indicates 
hemorrhage. 

Subarachnoid    Serous    Exudation    (Cerebral    Edema). — A 
severe  blow  upon  the  head,  with  or  without  fracture  of  the  skull, 
may  result  in  a  local  bruising  and  in  congestion  and  swelling  of 
the  brain-tissue,   with   serous  exudation  into  the  subarachnoid 
space,  either  with  or  without  edema  of  the  brain-substance.     If 
this  accumulation  of  fluid  occurs  over  the  motor  area,  localized 
symptoms,  as  if  of  hemorrhage,  may  appear.     The  lesion  is  usually 
self-limited,  the  resulting  paralysis  disappearing  in  the  cqurse^of  a_ 
few  days.     The  careful  observation  of  the  onset  and  sequence  1 
of  the  signs  of  compression  is  of  the  very  greatest  importance,  for 
it  is  by  a  proper  interpretation  of  these  localizing  symptoms  that    \ 
the  surgeon  is  led  to  operate,  and  then  is  enabled  to  remove  the     ' 
compressing  blood-clot  or  the  depressed  fragment  of  bone.  1 


Fig.  6. — Case  of  compound  depressed  fracture  of  the  frontal  bone.    Note  extent  of  depression. 
Recovery  (Harrington). 


Fig.  7.— Normal  skull.     Note  relations  of  facial  bones  in  connection  witii  figs.  16  and  18. 

22 


THE  FRACTURE  OF  THE  SKULL 


23 


THE  FRACTURE  OF  THE  SKULL 
WIkiIkt  ihv  wouiul  of  lliL'  bone  is  compound  or  simple,  open 
or  closed,  is  of  comparatively  little  importance,  because  of  the 
xerx  general  recognition  and  employment  of  aseptic  and  antisep- 
tic methods.     A  knowledge  of  the  nature  of  the  fracture  will  heli) 


Fig.  8. — Depressed  fracture  of  fron- 
tal bone  from  front,  showing  depres- 
sion of  fragments  (Warren  Museum, 
specimen  7951). 


Fig.  9. — Same  as  figure  8;  inner  surface  from 
below;  shows  excess  of  bone-formation. 


Fig.  10. — Depressed  fracture  of  right 
frontal  bone  :  a,  Point  toward  vertex  ;  b, 
anterior  corner ;  c,  lower  outer  end  (War- 
ren Museum,  4721). 


Fig.  II. — Same  from  within  ;  letters  as 
in  figure  10.  Fracture  shows  depression 
without  much  new  bone-formation  (War- 
ren Museum,  4721). 


in  determining  the  injurs-  to  the  brain.  If  there  is  a  perforating 
fracture,  or  if  the  fragments  are  comminuted  or  depressed,  then 
it  is  highly  probable  that  a  tremendous  or  sharply  localized  force 
has  been  exerted  upon  the  bone,  and  that,  in  consequence,  the 
injury  to  the  underlying  brain  is  serious.  It  is  a  generally  ac- 
cepted fact  that  the  skull  may  be  simply  contused  and  the  great 


24 


IfRACTURES   OF   THE   SKULL 


lateral  sinus  ruptured,  with  resulting  fatal  hemorrhage.  It  is 
likewise  true  that  the  bone  may  present  but  a  fissure,  but  if  that 
fissure  crosses  the  middle  meningeal  artery,  or  any  of  its  branches, 
they  may  be  torn  across,  and  the  consequent  hemorrhage  and 
associated  intracranial  pressure  will  prove  disastrous  unless 
checked  by  surgical  interference.  On  the  other  hand,  the  bone 
in  the  frontal  region  may  be  greatly  damaged,  literally  crushed, 
and  yet  no  grave  symptoms  arise  (see  Fig.  6).  The  extent  of  the 
bone-lesion  is,  however,  of  the  greatest  im- 
portance. 

Fractures  of  the  Vault  of  the  Skull  (see 

Fig.  8). — Fractures  of  the  vault  of  the  skull 

without  involvement   of  the  base  are  much 

more   unusual    than   is    generally    supposed. 

fwcKthirds  of  all  fractures  of  the 


Fig.  12. — No  fract- 
ure of  skull.  Hemato- 
maof  scalp, the  depress- 
ed center  and  firm  edge 
of  which  often  simulate 
fracture. 


vault  are  associated  with  fracture  of  the  base 
of  the  skull  (see  Figs.  8,  9,  10,  11).  Evi- 
dences of  fracture  of  the  vault  are  determined 
by  sight  and  touch.  A  wound  in  the  scalp 
may  disclose  the  fractured  bone.  Whether 
this  is  a  mere  fissure  or  a  single  or  a  commin- 
uted fracture,  whether  depressed  or  not  below 
the  general  surface  of  the  normal  skull,  can 
be  determined  only  by  careful  inspection.  A 
fissure  of  the  bone  may  be  difficult  of  recogni- 
tion. It  must  be  remembered  in  this  connec- 
tion that  blood  can  not  be  wiped  from  a  fissure, 
whereas  from  the  normal  suture  lines  it  can  readily  be  wiped  away. 
Blood  may  be  seen  escaping  through  a  fissure.  Torn  periosteum 
must  not  be  confused  with  a  fissure  of  the  bone. 

A  hematoma  of  the  scalp  may  suggest  a  depressed  fracture  of 
the  skull  (see  Fig.  12).  The  center  of  the  blood-tumor  is  soft; 
the  edges  are  edematous  and  hard.  If  the  finger  be  pressed  firmly 
into  the  soft  center,  an  intact  skull  generally  will  be  felt.  The 
uniform  edge  of  a  hematoma  is  unlike  the  irregular  jagged  edge 
of  a  fracture.  It  is  sometimes  impossible  to  distinguish  between 
a  hematoma  and  a  fracture  of  the  skull.  The  symptoms  of 
general  disturbance  are  of  course  more  marked  and  prolonged 


FRACTURE  OF  THE  BASE  OF  THE  SKULL 

Crista  sialli. 


25 


AntfHor  fossa. 


Foramen  rotundum 

Anterior  branch  niidiUc 

^meningeal  artery. 

Foramen  ovale. 

Foramen  spinosum. 


Petrous  portion  tem- 
poral bone. 


Lateral  sinus 


Cribriform  plate,  foramina 
for  olfactory  nerves. 


Optic  foramen. 
Middle  fossa. 

Foramen  lacerum  medium. 
Depression  for  Gasserian 
ganglion. 
—    Meatus  auditorius 
internus. 
Foramen  lacerum 
posterius. 

Foramen  magnum. 


Posterior  fossa . 


V\%.  i^.— Base  of  skull,  from  inside  and  above. 


crack. 


Fig.  14.  —  Punctate  fracture  entering 
posterior  fossa.  From  the  punctate  de- 
pression a  line  of  fracture  extends  down- 
ward and  backward  (Warren  Museum, 
specimen  965). 


Fig.  15.— Inner  view  of  figure  14,  showing 
comminution  of  inner  table  of  skull. 


2  6  FRACTURES    OF   THE    SKULL 

in  the  case  of  a  fracture  of  the  skull  than  when  only  a  hema- 
toma is  present. 

Fracture  of  the  Base  of  the  Skull  (see  Figs.  13,  14,  15). — It 
is  not  uncommon  to  discover  that  what  in  the  vault  appears  to 
be  a  simple  fissure  continues  down  to  and  involves  the  base  of  the 
skull.  Fractures  of  the  base  of  the  skull  are  usually  regarded,  and 
rightly  so,  as  more  serious  than  fractures  of  the  vault.  A  greater 
trauma  being  necessary  to  cause  the  fracture,  the  cerebral  dis- 
turbance is  more  pronounced  and  vital  parts  are  endangered. 
These  fractures  of  the  base  often  open  into  cavities  which  it  is  im- 
possible to  keep  surgically  clean — namely,  the  cavities  of  the  naso- 
pharynx and  the  ear.  The  danger  of  septic  infection,  therefore, 
in  such  fractures  is  very  great.     About  eighty-five  per  cent,  of 

basic  fractures  originate  in  the 
vault — i.  e. ,  are  caused  by  an  ex- 
tension of  a  linear  fracture  of  the 
vault  to  the  base.  A  few  basic 
fractures  are  due  to  forces  acting 
from  below  and  thus  causing  a 
,   ,   „        penetration  of   the   base   of   the 

Fig.   16. — Fracture   of  base  of  skull ;  ^ 

impaction   of  nasal  and  part  of  ethmoid  skull  by  Othcr  boueS.       The  facial 

bones,  which  project  into  the  interior  of  ,  i        c  i  •     j_      j.i 

the   cranium.     Male,  aged   twenty-eight;  DOUeS  may  be  forCcd  Up  mtO  the 

diagnosis,  fracture  of  nose.     Died  of  men-  anterior  foSSa  (sCC  Fig.   I  6).       The 
ingitis  (after  Helferich). 

articular  process  of  the  inferior 
maxillary  bone  may  be  pushed  up  through  the  glenoid  fossa  of  the 
temporal  bone  (see  Fig.  17)  into  the  middle  fossa  by  a  blow  upon 
the  chin,  particularly  if  the  jaw  is  relaxed.  The  vertebral  column 
may  be  forced  up  into  the  posterior  fossa  through  a  fracture  of 
the  occiput. 

Symptoms  of  Fracture  of  the  Base. — Hemorrhage  may  take 
place  from  the  ear,  from  the  nose,  from  the  mouth  or  be  noticed 
under  the  conjunctiva.  Occasionally  blood  is  seen  in  all  four 
situations.  Hemorrhage  may  occur  beneath  the  pharyngeal 
mucous  membrane.  Escape  of  cerebrospinal  fluid  from  the  ear 
and  nose  may  be  noticed.  Brain-tissue  sometimes  escapes  from 
the  skull  and  is  seen  lying  in  the  external  auditory  meatus  or  near 
a  wound  which  communicates  with  the  fracture  of  the  skull. 
Injuries  may  occur  to  the  third,  fifth,  seventh  and  eighth  nerves. 


SYMPTOMS   OK    I-RACTURE   OF   THE    BASE  27 

Associated  with  these  local  signs  may   be   the  general  signs   of 
concussion  or  laceration  of  the  brain. 


Posterior  nares. 


Glenoid  fossa. 


External  pterygoid 
plate. 


Fig.  17.— Showing  thinness  of  the  roof  of  the  glenoid  fossa,  which  is  occasionally  broken  by 
the  condylar  process  of  the  inferior  maxilla  when  a  blow  is  received  on  the  jaw. 


Frontal  sinus. 


Sphenoidal  sinus.        Cribriform  plate. 
Fig.  iS.— Median  section.     Anterior  portion  of  skull,  showing  thinness  of  the  ethmoid  plate, 
which  alone  separates  the  cavities  of  nose  and  skull. 


If  the  orbital  plate  of  the  frontal  bone  is  broken,  blood  Avill 
gravitate  into  the  orbit ;  ecchymosis  of  the  lids  and  subconjunc- 


2  8  FRACTURES   OF   THE   SKULL 

tival  hemorrhage  will  appear.  There  may  be  greater  tension  of 
the  eyeball  upon  the  affected  side,  detected  by  palpating  the  globe 
through  the  closed  lid.  vSubconjunctival  hemorrhage  may  appear 
from  a  fracture  of  the  malar  or  superior  maxillary  bones. 

If  the  cribriform  plate  of  the  ethmoid  is  fractured,  hemorrhage 
from  the  nose  will  occur  (see  Fig.  i8).  Impairment  of  the  sense 
of  smell  may  exist  if  the  olfactory  nerves  become  involved  in  the 
fracture.  Blood  may  trickle  from  a  fracture  of  the  base  into  the 
pharynx,  be  swallowed,  and  later  vomited.  Epistaxis,  of  course, 
may  be  due  to  a  blow  upon  the  face  without  fracture  of  the  base. 
If  inspection  discloses  a  broken  nose  or  ecchymosis  of  the  face  or 


Fig.  19. — Fracture  of  the  base  of  the  skull,  involving  the  middle  and  posterior  fossae  on  the 
left  (Warren  Museum,  5106). 


the  skin  of  the  forehead,  it  is  very  probable  that  the  minor  acci- 
dent has  occurred. 

Most  fractures  of  the  base  involve  the  middle  fossa.  If  the 
petrous  portion  of  the  temporal  bone  is  fractured,  several  im- 
portant signs  appear  (see  Fig.  19).  If  the  tympanum  is  torn, 
hemorrhage  from  the  external  auditory  meatus  is  sure  to  follow. 
If  this  hemorrhage  is  continuous,  it  is  significant;  if  it  is  trifling 
and  temporary,  it  is  probably  unimportant  and  may  be  local. 
Cerebral  tissue  may  escape  from  the  nose,  thus  establishing  the 
seat  of  the  lesion.  Cerebrospinal  fluid  may  likewise  escape  from 
the  ear.  Cerebral  tissue  may  also  appear  at  the  external  auditory 
meatus.  Any  of  these  signs  is  conclusive  evidence  that  the  base 
of  the  skull  is  fractured  and  that  there  is  a  lesion  of  the  brain. 
Lesions  of  the  facial  (seventh)  and  auditory  (eighth)  nerves  lying 


SYMPTOMS  OK  KRACTURK  OF  THE  BASE.  29 

within  the  bones  oecur.  Lesions  are  hkewise  reported  of  the  fifth 
nerve,  because  of  its  lying  upon  the  fractured  petrous  portion  of 
the  temporal  bone.  Subconjunctival  hemorrhage  may  appear, 
owing  to  the  blood  working  its  way  forward  through  the  sphenoi- 
dal fissure  and  the  optic  foramen.  A  primarv  profuse  watery 
discharge  from  the  nose  or  the  ear  is  probably  cerebrospinal  fluid. 


Fig.  20. — The  three  fossae  of  the  base  of  the  skull. 

A  watery  discharge  appearing  late  after  such  an  injury  is  likely 
to  be  serum  from  a  blood-clot.  The  optic  nerve  may  be  involved 
in  the  injury  with  resulting  blindness. 

If  the  posterior  fossa  (see  Fig.  20)  is  involved  in  the  fracture, 
there  may  be  hemorrhage  into  the  phars'nx.  Ecchymosis  under 
the  pharyngeal  mucous  membrane  may^  be  present  wdthout  actual 
rupture  of  the  mucous  membrane.     A  fullness  may  be  detected 


30  FRACTURES    OF    THE    SKULE 

by  palpation  in  the  posterior  wall  of  the  pharynx,  if  the  hemor- 
rhage there  is  considerable.  Ecchymosis  just  in  front  of  the  mas- 
toid process,  or  a  hematoma  and  puffy  swelling  over  the  seat  of 
the  fracture,  may  determine  its  location. 

Unconsciousness  Resulting  from  Other  than  Surgical 
Causes. — There  are  certain  conditions  associated  with  loss  of  con- 
sciousness and  delirium  which  must  be  differentiated  from  trau- 
matic intracranial  lesions.  These  conditions  are  (a)  the  coma 
from  opium-poisoning ;  (h)  the  unconsciousness  in  uremia ;  (c)  the 
loss  of  consciousness  from  apoplexy;  (d)  alcoholic  coma;  and 
(e)  hemorrhagic  internal  pachymeningitis. 

Coma  from  Opium-poisoning :  The  patient  can  be  aroused  un- 
less the  poisoning  is  extremely  profound,  and  can  be  made  to 
understand,  and  will  even  reply  to  an  inquiry.  The  face  at  first 
is  pale,  later  it  is  flushed  and  swollen.  The  skin  is  warm  and 
moist.  The  respiration  is  slow.  The  temperature  is  subnormal. 
The  pulse  is  slow  and  full.  The  pupils  are  strongly,  immovably, 
and  symmetrically  contracted.     The  reflexes  may  be  absent. 

The  Unconsciousness  in  Uremia:  The  patient  can  not  be 
aroused.  The  face  is  white,  edematous,  and  puffy.  The  breath 
has  a  sweetish  odor.  The  respiration  is  frequent  and  irregular. 
The  temperature  is  normal.  The  pulse  is  rapid.  The  pupils 
are  dilated  and  sluggish.     The  urine  usually  contains  albumin. 

The  Unconsciousness  from  Apoplexy :  The  patient  can  not  be 
aroused.  The  respiration  is  slow,  irregular,  and  stertorous.  The 
temperature  is  subnormal  at  first ;  if  a  fatal  termination  is  proba- 
ble, the  temperature  is  high.  The  pupils  are  dilated.  Unilateral 
paralysis  of  the  face  and  the  extremities  usually  is  present.  The 
affected  extremities  are  warmer  than  those  of  the  other  side.  The 
limbs  may  be  relaxed,  but  in  watching  the  patient  carefully  evi- 
dences of  hemiplegia  will  appear.  The  history  of  previous  hemor- 
rhages may  be  discovered  pointing  to  hemorrhagic  internal 
pachymeningitis. 

Alcoholic  Coma :  The  patient  can  be  aroused  bv  pressure  upon 
the  supra-orbital  nerves — sometimes,  however,  with  great  diffi- 
culty. The  breath  may  be  alcoholic.  The  face  is  flushed.  The 
respiration  is  regular.  The  pulse  is  rapid.  The  temperature  is 
normal  or  low.     The  pupils  are  normal.     There  is  an  absence  of 


EXAMINATION    OF    THIC    PATIENT  3 1 

the  positive  signs  of  a  cerebral  lesion.  The  temperature  in  cere- 
bral laceration  is  elevated.  Alcoholic  delirium  will  present  an 
elevated  temperature,  but  along  with  the  elevated  temperature 
of  a  lacerated  brain  there  will  be  symptoms  characteristic  of  a 
damaged  brain. 

Hemorrhagic  Internal  Pachymeningitis:  The  occurrence  of 
apoplectic  seizures  during  the  course  of  this  disease  makes  it  im- 
portant that  it  be  recognized  in  connection  with  the  distinctly 
traumatic  hemorrhages  under  consideration.  The  characteristic 
course  shows  an  acute  diffused  affection  of  the  brain,  usually  in 
an  elderly  man  and  with  severe  symptoms.  An  acute  attack 
is  followed  by  a  fair  recovery  and  by  interA^als  of  comparative 
health.  During  these  intervals  of  comparative  health  the  patient 
has  some  headache,  slight  diminution  of  intelligence,  impairment 
of  memory,  drowsiness,  partial  paralysis  of  the  limbs  (usually 
unilateral),  disturbances  of  speech,  and  sudden  mental  excitement 
without  cause  mixed  with  symptoms  of  paralytic  dementia.  Evi- 
dences of  a  sudden  and  increasing  compression  are  headache, 
drowsiness,  loss  of  consciousness,  some  fever,  a  pulse  of  compres- 
sion, and  sometimes  initial  symptoms  of  irritation.  The  diag- 
nosis is  assisted  by  the  etiology  and  history  of  the  case.  In  mid- 
dle meningeal  hemorrhage  a  blow  is  necessarv"  to  cause  alarming 
symptoms,  whereas  in  hemorrhagic  pachymeningitis  a  vers^  trivial 
injurs'  or  none  at  all  is  common.  The  longer  duration  of  the 
symptoms  would  help  to  decide  against  middle  meningeal  hemor- 
rhage. There  is  often  a  rigidity  of  the  limbs  in  hemorrhagic  pachy- 
meningitis which  is  absent  in  middle  meningeal  hemorrhage  cases. 

When  called  upon  to  see  a  case  of  head-injury,  it  must  be 
remembered  that  the  lesion  can  not  always  be  determined  by  the 
first  observation  of  the  patient.  It  is  absolutely  necessary  that 
there  be,  upon  the  part  of  the  physician,  a  clear  understanding 
of  the  method  of  onset  and  the  sequence  of  symptoms  from  the 
receipt  of  the  injury.  Isolated  signs  are  of  less  importance  than 
relative  symptoms. 

Examination  of  the  Patient. — The  following  comprehensive 
method  of  examining  an  individual  who  has  received  a  severe 
injur}'  to  the  head  should  be  carefully  followed,  bearing  in  mind 
always  the  possible  cranial  and  intracranial  lesions,  and  remem- 


32  FRACTURES   OF   THE   SKULL 

bering  that  a  fracture  of  the  skull  as  such  is  of  secondary  impor- 
tance, that  an  injury  to  the  intracranial  vessels  is  serious,  and  that 
a  lesion  of  the  brain  itself  is  most  important. 

If  with  brain  symptoms  there  is  no  visible  injury  to  the  skull, 
the  head  should  be  shaved  to  facilitate  careful  examination. 
Acute  localized  pain  suggests  the  seat  of  fracture. 

When  was  the  accident?  How  much  time  has  elapsed  between 
the  accident  and  the  first  accurate  observation? 

What  was  the  accident  ?     Was  it  a  fall  or  a  blow  ? 

What  is  the  age  of  the  patient?  Are  the  arteries  atheroma- 
tous, and  therefore  easily  ruptured  by  trivial  injury?  Is  it  the 
skull  of  a  child — which  is  softer  and  less  brittle  than  that  of  an 
adult? 

What  was  the  condition  of  health  previous  to  the  accident? 
Was  it  poor — suggestive  of  kidney-disease  and  uremia  ?  Was  the 
man  alcoholic,  or  is  the  present  condition  masked  by  alcohol  taken 
subsequent  to  the  accident? 

The  General  Condition  of  the  Patient:  If  unconsciousness  is 
present,  was  its  onset  immediate,  or  was  there  a  lucid  interval 
after  the  accident?  Has  the  unconsciousness  been  continuous, 
and  is  it  deepening  or  lessening  ? 

What  are  the  evidences  of  shock  present?  What  is  the  condi- 
tion of  the  pulse,  of  the  respiration,  of  the  skin?  What  is  the 
temperature  taken  in  the  rectum?  Has  vomiting  occurred? 
Have  there  been  involuntary  dejections?  Has  there  been  invol- 
untary micturition? 

The  Local  Condition :  The  wound  of  the  scalp  or  skull  or  brain 
maybe  evident.  If  hemorrhage  is  present,  what  is  its  source? 
Is  it  from  the  nose,  the  mouth,  the  ear,  or  into  the  orbit  ?  When 
did  the  hemorrhage  occur?  What  was  its  amount?  Was  it  con- 
tinuous or  not  ?  Palpation  should  be  made  of  the  skull,  the  neck, 
the  face,  the  spine,  the  jaw,  and  the  temporo-maxillary  joint. 

Are  any  localizing  signs  present  ?  What  is  the  condition  of  the 
pupils,  and  of  the  muscles  of  the  face,  the  arms,  and  the  legs? 
What  is  the  condition  of  the  reflexes  and  of  the  respiration  ?  Does 
hemiplegia,  either  partial  or  complete,  exist  ? 

Finally,  the  whole  body  should  be  examined  systematically 
for  any  other  injuries  than  those  to  the  head  and  to  the  nervous 


GENERAL    OBSERVATIONS  33 

system.  Associated  injuries,  if  discovered,  may  assist  in  inter- 
preting the  nature  of  the  cerebral  injury. 

A  diagnosis  nnist  be  based  upon  all  available  evidence.  One 
will  have  to  consider  concussion  and  laceration  of  the  brain  and 
pressure  upon  the  brain  by  serum,  blood,  and  bone.  The  im- 
portant signs  to  be  studied  in  diagnosis  are  the  different  aspects 
of  unconsciousness;  the  relative  and  actual  conditions  of  the 
respiration,  pulse,  and  temperature ;  the  occurrence  of  hemor- 
rhage; restlessness  and  muscular  twitching;  localizing  signs  of 
pressure.  If  the  symptoms  are  not  positive,  if  there  is  no  history 
of  trauma,  if  the  histor\-  of  a  lucid  interval  preceding  uncon- 
sciousness is  doubtful,  or  if  there  is  no  histor\-  at  all,  then  the 
diagnosis  will  be  most  difficult.  It  is  when  positive  symptoms 
are  absent  that  one  must  particularly  consider  those  conditions 
already  mentioned  in  which  coma  is  a  prominent  sign — namelv, 
opium-poisoning,  uremia,  apoplexy,  alcoholism. 

General  Observations. — An  unconscious  man  having  a  scalp 
wound  and  a  breath  smelling  of  liquor  is  not,  necessarilv,  drunk. 
He  may  have  an  intracranial  lesion.  ^lultiple  lesions  may  be 
present  in  any  case.  A  diffuse  lesion  may  obscure  a  localized 
lesion.  Xot  only  must  the  location  of  a  lesion  be  determined,  but 
also  its  character,  if  possible.  The  symptoms  must  be  recorded 
in  the  order  of  their  appearance.  The  manner  in  which  various 
symptoms  develop  should  be  noted.  The  danger  to  the  brain  is 
greatest  in  perforating  and  sharply  depressed  fractures.  Slight 
fissures  may  be  associated  with  extensive  hemorrhages.  Great 
comminution  of  bone  may  be  devoid  of  much  danger.  In  cases 
of  compound  fracture  fissures  apparently  closed  afford  the  possi- 
bility of  cerebral  and  meningeal  infection  through  dirt  having 
entered  when  the  fissure  was  open. 

Unconsciousness  and  a  superficial  head-lesion,  with  or  without 
fracture  of  the  skull,  must  make  one  suspicious  of  an  intracranial 
lesion.  An  immediate  loss  of  consciousness  indicates  a  diffused 
contusion  or  concussion  of  the  brain.  If  the  primary  uncon- 
sciousness is  prolonged,  probably  hemorrhage  has  occurred,  or 
possibly  a  serous  exudation  with  its  resulting  pressure  upon  the 
brain.  If  there  is  a  conscious  inter^-al  preceding  the  unconscious- 
ness,   a   hemorrhage   is    probable.     Momentar\-   unconsciousness 


34  FRACTURES   OF   THE   SKULL 

means  concussion.  Recurring  unconscious  periods  indicate  hem- 
orrhage. Deepening  unconsciousness  indicates  increasing  intra- 
cranial pressure — probably  hemorrhage.  Immediate  profound 
unconsciousness  suggests  hemorrhage  from  the  rupture  of  an  in- 
tracranial sinus. 

The  temperature  in  all  intracranial  lesions  is  usually  slightly 
above  normal.  Intoxication  and  shock  depress  the  temperature. 
In  a  small  intracranial  hemorrhage  there  will  be  a  slight  rise  of 
temperature,  perhaps  to  99°  F.,  following  the  initial  drop  a  few 
hours  after  the  injury.  In  cerebral  laceration  one  finds  a  higher 
initial  temperature  than  in  hemorrhage,  and  in  fatal  cases  the 
temperature  remains  elevated.  If  the  temperature  rises  quickly 
and  early,  a  considerable  laceration  is  present;  if  after  several 
hours  of  unconsciousness  the  temperature  remains  about  99°  or 
99.5°  F.,  there  is  probably  a  hemorrhage  rather  than  a  severe 
direct  lesion;  if,  on  the  other  hand,  the  temperature  rises  higher, 
there  is  a  cerebral  lesion,  alone  or  associated  with  a  hemorrhage. 
If  the  temperature  does  not  rise  very  high  and  advances  rather 
slowly,  there  is  a  contusion  or  a  concussion  with  slight  laceration 
or  a  slight  hemorrhage.  A  slow,  full  pulse  with  stertorous  respira- 
tion suggests  pressure;  it  may  be  from  extradural  hemorrhage. 
Barly  and  very  slow  respiration  is  associated  with  pressure  upon 
the  medulla. 

Paralysis  of  the  limbs  and  the  face  is  characteristic  of  serous 
exudation,  hemorrhage,  or  bony  pressure.  Irregular  muscular 
contractions  suggest  laceration  of  motor  areas.  Mental  disturb- 
ance may  be  due  to  cerebral  lesions.  That  brain-tissue  escapes 
from  the  ear  does  not  necessarily  signify  that  the  patient  will  not 
recover.  Fractures  of  the  base  of  the  skull  occur  without  marked 
symptoms  and  recover  without  the  necessity  of  operation. 

Treatment. — There  are  cases  of  injury  to  the  skull  so  serious 
that  it  is  evident  that  operation  will  be  of  no  avail.  There  are 
cases  of  simple  concussion  in  which  only  careful  nursing  is  de- 
manded. There  is  a  large  and  increasing  number  of  serious  head- 
accidents  in  which  operative  interference  will  prove  of  great  value. 
The  collapse  from  shock  may  be  well-nigh  complete,  but  restora- 
tive measures  are  not  to  be  neglected  upon  this  account.  If 
hemorrhage  is  suspected,  stimulation  of  the  circulation  must  be 


TREATMEXT    01*    FRACTURES    OF    THFC    SKULL  35 

ven'  guarded.  The  patient  should  be  placed  horizontally,  with 
the  head  slightly  raised,  and  kept  quiet.  The  whole  body  should 
be  wrapped  in  warm  blankets.  Warm  water-bottles  should  be 
put  on  the  outside  of  the  bed  about  the  patient  not  next  the  skin, 
one  at  each  foot,  three  along  each  side  of  the  body.  The  water 
in  these  bottles  should  be  comfortably  warmed — 110°  F.  Hot 
water  is  never  to  be  used.  Patients  under  these  circumstances 
are  insensible  to  heat,  and  severe  burning  of  the  skin  may  occur  if 
ver\'  hot  water  is  used  in  the  bottles. 

If  there  are  no  indications  for  immediate  operation,  and  local- 
izing symptoms  are  absent,  the  patient  is  to  be  treated  sympto- 
matically.  The  pulse  is  to  be  carefully  watched  to  detect  varia- 
tions in  strength,  rate,  and  rhythm.  The  character  and  frequency 
of  the  breathing  are  to  be  likewise  noted.  Gentle  stimulation  sub- 
cutaneously  by  sulphate  of  strychnin  (^^  of  a  grain),  administered 
as  needed,  will  often  steady  a  pulse  remarkably.  A  special  nurse 
or  an  intelligent  watcher  should  be  with  the  patient  constantly, 
to  note  any  localizing  signs  of  pressure,  such  as  twitching  of  the 
muscles  of  the  face  or  limbs  and  variations  in  the  pupil,  to  record 
movements  of  the  limbs,  and  to  make  hourly  obserA'ations  of  the 
pulse,  temperature,  and  respiration,  and  any  variation  in  con- 
sciousness. These  observations  will  be  of  inestimable  value  in 
determining  diagnosis,  prognosis,  and  treatment. 

The  various  cavities  exposing  the  brain  to  infection  should  be 
cleansed. 

The  Xose. — The  nose  should  be  douched  with  boric  acid  solu- 
tion (i  :  30),  and  plugs  of  sterilized  absorbent  cotton  should  be 
placed  in  each  nostril. 

The  Ear. — The  ear  should  be  douched  with  boric  acid  solution 
(i  :  30 j,  and  dried  carefully  with  small  wisps  of  cotton.  Boric 
acid  powder  should  then  be  blown  gently  into  the  external  audi- 
tory- meatus.  A  bit  of  sterilized  gauze  or  absorbent  cotton  may 
be  left  in  the  meatus. 

The  Scalp. — The  directions  for  cleansing  the  scalp  pertain  to 
cases  with  or  without  scalp  w'ounds  associated  with  important 
cerebral  symptoms.  The  whole  scalp  should  be  shaved,  scrubbed 
with  hot  water  and  soap,  with  chlorinated  soda  solution  (i  :  20), 
with  boiled  water,   and  then  with  corrosive  sublimate  solution 


FRACTURES    OF    THE    SKULL 


(i  :  looo),  and  covered  with  a  dressing  of  sterilized  gauze  that  has 
been  moistened  in  a  solution  of  corrosive  sublimate  (i  :  5000). 
The  wound  of  the  soft  parts  should  be  carefullv  irrigated  with 
sterilized  salt  solution,  and  sponged  and  swabbed  with  great  care 
with  corrosive  sublimate  solution  (i  :  5000).  The  swabs  used 
should  be  tiny  ones,  so  as  to  reach  to  the  smallest  recesses  of  the 
wound.  Corrosive  sublimate  solution  should  not  be  allowed  to 
touch  the  brain-tissue. 

The   Mouth. — Thorough    cleansing,    with    corrosive    sublimate 
solution  (i  :  3000),  of  the  teeth  and  tongue  and  all  the  folds  of  the 

mucous  membrane  about  the  lower 
and  upper  jaws  is  important.  The 
swabbing  of  the  tonsils  and  the 
posterior  pharyngeal  wall,  the  care 
of  the  nose  and  the  ear, — these  pro- 
cedures will  reduce  to  a  minimum 
the  chances  of  infection.  The  nose 
and  mouth  will  require  constant  at- 
tention. The  ear  will  require  at 
least  daily  cleansing.  The  fre- 
quency of  the  cleansing  required 
will  depend  A^ery  largely  upon  the 
amount  of  moisture  and  discharge 
from  the  part  involved.  If  the 
packing  of  cotton  soon  becomes 
moistened,  the  douching  should  be  repeated,  and  fresh,  dry  pack- 
ing should  replace  the  old. 

If  there  is  great  restlessness,  it  may  be  necessary  to  restrain  the 
patient,  that  he  may  not  harm  himself.  This  is  done  by  means  of 
a  sheet  folded  and  passed  about  the  bed  and  body  of  the  patient. 
Operative  interference  is  demanded  in  penetrating  or  sharply 
depressed  fractures,  in  all  compound  fractures,  and  in  all  simple 
fractures  with  symptoms  of  intracranial  hemorrhage  increasing 
in  severity  or  distinctty  localized  (see  Figs.  21,  22,  23).  Opera- 
tion should  be  undertaken  in  these  cases  for  three  distinct  rea- 
sons: to  insure  cleanliness,  to  elevate  and,  if  necessary,  remove 
bony  fragments,  and  to  check  hemorrhage.  The  details  of  opera- 
tive treatment  must  necessarilv  be  omitted. 


Fig.  21. — Sites  where  extradural  hemor- 
rhage is  usually  found. 


TREATMENT  OF  FRACTURES  OF  THE  SKULL 


37 


All  cases  of  injury  to  the  head,  even  cases  of  simple  nondepressed 
fracture  of  the  skull  \vithout  symptoms,  are  to  be  watched  with 
great  care  by  trained  observers  for  at  least  one  month  following 


b 


Fig.  22. — Location  of  anterior  branch  of  middle  meningeal  artery.  Draw  a  line  from 
the  glabella  backward  {a  d),  parallel  to  the  line  6  c,  from  the  lower  edge  of  the  orbit  through 
the  external  meatus.  Line  from  glabella  to  mastoid,  a  e.  From  the  middle  of  this  last  line, 
a  line  drawn  perpendicular  to  it  will  intersect  the  line  a  rf  at  about  the  site  of  the  arten.'.  A 
line  running  from  the  front  of  the  mastoid  perpendicular  to  the  line  b  c  intersects  a  dzX.  about 
the  site  of  the  posterior  branch. 


Fig.  23. — Perpendicular  lines  from  the  mastoid  and  from  just  in  front  of  the  ear  include  tlie 
motor  area  of  the  central  convolutions.     The  fissure  of  Rolando  is  shown. 


the  accident,  and  then  are  to  be  seen  at  inter\-als  for  many  months 
afterward.  The  reason  for  this  prolonged  obserA'ation  is  that 
meningeal  hemorrhage  may  develop  in  the  immediate  future,  and 


38     .  FRACTURES    OF    THE    SKULL 

that  after  an  interval  of  months  a  brain-abscess  may  manifest 
its  presence. 

In  fracture  of  the  base  with  pronounced  symptoms,  drainage 
of  the  fossa  involved,  whether  anterior,  middle,  or  posterior, 
should  be  considered.     It  has  occasionally  been  of  service. 

Prognosis. — The  prognosis  of  head-injuries  is  the  prognosis 
of  their  complications  and  sequela?.  Prolonged  unconsciousness 
is  not  usually  dangerous  in  itself.  Late  unconsciousness  is  dan- 
gerous. The  severity  rather  than  the  form  of  the  lesion  is  to  be 
made  the  basis  of  prognosis.  The  temperature  is  of  great  value 
in  prognosis.  By  its  persistent  depression  the  danger  from  pri- 
mary shock  is  gauged ;  a  little  later  in  the  course  of  the  case  the 
amount  of  hemorrhage  is  judged  by  it ;  later  still,  its  rapid  and  pro- 
gressive rise  will  denote  the  magnitude  or  severity  of  a  meningeal 
or  cerebral  lesion.  A  temperature  as  high  as  105°  F.  is  of  grave 
prognosis.  A  sudden  rise  of  temperature  late  in  the  progress  of  a 
case,  probably  due  to  a  meningitis,  or  a  continued  subnormal 
temperature  at  any  time  after  the  reaction  from  the  primary 
shock,  is  always  an  unfavorable  sign.  Symptoms  often  change 
suddenly  in  cases  apparently  doing  well.  One's  prognosis  must, 
therefore,  always  be  guarded. 


LATER  RESULTS  OF  FRACTURE  OF  THE  SKULL 

Very  little  is  known  of  these  cases  in  this  country.  Dr.  Bul- 
lard,  of  the  Boston  City  Hospital,  has  contributed  so  valuable  a 
paper  upon  this  subject  that  the  results  are  here  stated :  Seventy 
patients  were  examined  after  having  had  fracture  of  the  skull :  37 
presented  no  symptoms  when  examined  some  time  later.  The 
most  frequent  consequences  were  headache,  deafness,  dizziness, 
and  inability  to  resist  the  action  of  alcohol  on  the  brain.  Out  of 
1 5  cases  in  which  operation  (trephining)  was  performed,  1 2  had  no 
resulting  symptoms;  in  one  case  it  was  doubtful  whether  the 
symptoms  present  were  due  to  injury ;  in  one  case  the  symptoms 
were  slight  (headache  rare,  tension  over  the  wound  while  lying  in 
bed).     The  other  case  was  deaf,  but  had  no  other  trouble. 

Dr.  Bullard  concludes,  so  far  as  these  statistics  lead,  that  those 
cases  in  which  trephining  was  performed  have  shown  much  better 


ILLUSTRATIVE    CASES  39 

results,  so  far  as  the  symptoms  previously   meutioned  are  con- 
cerned, than  those  in  which  no  operation  was  performed. 

CASES  OF  HEAD  INJURY 
The  following  cases,  related  in  some  detail,  illustrate  a  few  of 
the  varieties  of  injuries  to  the  head  from  a  clinical  standpoint : 

Case  I.— A  fall  upon  the  head.— No  visible  evidences  of  injury.— An 
inte?-val  of  consciousness  followed  by  unco?isciousness.— Localizing  signs 
of  pressure.— Diagnosis,  middle  meningeal  hemorrhage  with  fracture 
of  ,knii  ^Operation.— Fracture  and  hemorrhage  fo2ind.— Recovery. 

M    A.   B ,  sixty-nine   years  old,  a  spinster,  fell,   upon   being 

struck  by  a  coasting-sled,  one  and  one-half  hours  previous  to  the  exam- 
ination. ,  _  1  •    1     u        u 

Examination.— She  does  not  know  of  the  accident  which  has  be- 
fallen her.  She  talks  coherendy.  She  recognizes  her  sister.  There 
is  slight  shock.  The  pulse  is  64  and  of  fair  strength  ;  the  respira- 
tion is  16  ;  the  temperature  is  97.5°  F-  There  is  bleeding  from  the 
right  ear  There  is  some  dry  blood  about  the  nostrils.  Ihere  is  no 
visible  external  injury.  There  is  no  paralysis.  All  the  superficial 
reflexes  are  present.  The  pupils  are  contracted  equally  and  react  to 
light.  The  patient  is  not  very  restless,  although  she  talks  consider- 
ably and  affirms  again  and  again  that  she  is  not  hurt. 

The  ears  were  washed  out  carefully  and  treated  antiseptically.  _ 
She  vomited  two  or  three  times  during  the  night.  She  was  quite 
restless,  moving  and  turning  in  bed.  She  slept  two  or  three  hours 
altogether.  There  were  no  evidences  of  intracranial  pressure  m  the 
morning.  At  about  noon  of  the  second  day  she  talked  a  little  inco- 
herently. She  did  not  answer  questions  as  readily  as  m  the  morning. 
At  X  o'clock  in  the  afternoon  of  the  second  day  examination  finds 
the  pupils  equal  and  reacting  to  light.  She  understands  what  is  said 
to  her,  but  does  not  talk  coherently  or  distinctly.  There  is  almost 
complete  paralysis  of  the  right  arm.  There  is  paresis  of  the  right  leg 
The  face  is  not  paralyzed.  The  pulse  has  increased  in  rate  to  85  and 
is  particularly  full  and  bounding.  The  knee-jerk  is  much  less  active 
upon  the  right  than  upon  the  left  side. 

At  4.30  P.M.,  one  and  one-half  hours  after  the  previous  observa- 
tion, all  the  symptoms  were  considerably  intensified.  The  face  was 
uneven,  the  wrinkles  being  most  marked  on  the  left.  The  breathing 
was  becoming  labored  and  almost  stertorous.  It  was  hard  to  arouse 
the  woman.  She  moved  the  left  arm  freely.  The  right  arm  she  moved 
slightly  or  not  at  all.  There  were  no  abdominal  reflexes  active.  -Bleed- 
ina  from  the  right  ear  continued  to  a  slight  extent  all  day. 

A  diagnosis  of  middle  meningeal  hemorrhage  on  the  left  side  was 

made.     Immediate  operation  was  decided  upon.  ,     1  r^ 

Under  ether  anesthesia  an  elliptic  incision  was  made  upon  the  lett 

side  of  the  head,  beginning  just  in  front  of  the  ear,  and  was  carried 


40 


INJURIES   TO   THE   HEAD 


up  across  the  temporal  muscle  and  down  to  the  zygoma  of  the  same 
side.  A  quarter-inch  trephine  was  used.  The  hemorrhage  was  found 
to  be  from  a  branch  of  the  middle  meningeal  artery,  and  from  within 
the  dura,  which  was  lacerated.  A  large  clot  and  much  fresh  blood 
were  lying  over  the  temporal  and  parietal  regions.  This  blood  was 
carefully  sponged  away.  The  middle  meningeal  branch  was  tied 
with  a  silk  ligature.  Gauze  wicks  were  placed  well  down  deep 
toward  the  base  of  the  skull.  The  dura  was  not  sutured.  The  bleed- 
ing vessels  of  the  diploe  were  stopped  with  wax.  The  skin  flap  was 
replaced  and  sutured,  leaving  a  small  gauze  drain  down  to  the  dura. 
The  pulse  was  poor,  and  there  was  evidence  of  considerable  shock 
at  the  conclusion  of  the  operation.  Proper  stimulation  with  strych- 
nin and  enemata  of  salt  solution 
and  brandy  had  a  good  effect. 
The  temperature  rose  to  i  io°  F. 
during  the  night,  but  dropped 
immediately  and  gradually  came 
to  normal. 

The  following  day  uncon- 
sciousness was  present,  the  par- 
alysis was  unrelieved,  the 
breathing  was  stertorous  and 
puffing. 

The  second  day  after  the  op- 
eration the  gauze  drain  was  re- 
moved and  two  smaller  gauze 
drains  were  inserted.  Some 
signs  of  consciousness  appear. 
She  takes  notice  of  people  com- 
ing into  the  room. 

The  fifth   day  following   the 
operation  she    notices   friends. 
The  paralysis  is  still  present. 
The  sixth  day  after  the  op- 
Fig.  24.— Case  i.    Line  of  incision  shown.         eration  she  moves  the  right  leg 

a  little.  No  articulate  speech 
is  present.  Understands  questions  and  grunts  in  answer  to  all  ques- 
tions.    She  can  express  no  idea  in  words. 

The  tenth  day  after  the  operation  she  moves  the  right  arm.  The 
mental  condition  is  clearer. 

On  the  eighteenth  day  she  moves  the  right  leg,  and  the  arm  has 
more  power. 

The  thirtieth  day  was  an  important  one  for  the  patient.  She  walked 
alone  for  the  first  time  since  the  accident. 

One  year  after  the  accident  the  patient  is  found  to  be  having  occa- 
sional attacks  of  dizziness,  accompanied  by  "  falling- fits."  She  is 
perfectly  sane,  and  talks,  often  very  well ;  then  there  come  times  of 
difficulty  in  talking,  when  she  can  not  find  the  right  word  to  express 
herself.  Just  after  one  of  these  attacks  of  fainting,  etc.,  talking  is  less 
easy. 


ILLUSTRATIVE   CASES 


41 


Three  years  after  the  operation  the  foUowiiiL,^  examination  was  made: 
The  speech  is  thick,  slow,  and  with  effort.  The  facial  muscles  of  the 
left  side  are  stiff  and  slightly  drawn  ;  they  do  not  move  so  well  as  on 
the  right  side.  The  left  nasolabial  fold  is  more  accentuated  than  the 
right.  The  left  eyebrow  is  lower  than  the  right.  The  patient  thinks 
that  she  can  hear  better  with  the  right  ear  than  with  the  left.  The 
right  hand  gets  cold  "and  does  not  look  natural."  The  right  fore- 
finger is  often  whiter  than  the  other  fingers  of  the  right  hand.  It  is 
difficult  to  pick  up  needles  or  pins  with  the  fingers  of  the  right  hand. 
There  is  no  increase  in  the  Avrist-jerks.  The  knee-jerk  is  slightly 
greater  on  the  right  side  than  on  the  left. 

The  patient  says  she  is  enjoying  excellent  health,  eats  and  sleeps 
well,  and  is  out  of  doors  much  of  the  time.  She  is  taking  bromid 
of  potassium  regularly  once  a  day 
in  small  doses.  About  once  a  month 
she  has  a  fainting  or  ' '  weak  spell. ' ' 
These  attacks  are  growing  less  pro- 
nounced and  less  frequent. 

This  case  illustrates  the  important 
fact  that  after  a  severe  head  injury 
with  almost  no  external  visible  sign, 
the  patient  should  be  kept  under 
very  careful  observation  through  the 
hours  immediately  succeeding  the 
accident.  Relative  symptoms  are 
of  far  greater  importance  in  head 
injuries  than  isolated  observations. 
Bleeding  from  the  ear  as  a  symptom 
in  head  injuries  does  not  necessarily 
imply  fracture  of  the  petrous  portion 
of  the  temporal  bone.  Rupture  of 
the  tympanum  may  cause  bleeding 
from  the  ear.  There  was  no  frac- 
ture of  the  skull  detected  after  care- 
ful examination  in  this  case. 

The  interval  of  consciousness  in 
this  case  was  a  somewhat  short  and 

hazy  one.  Immediately  after  the  accident  the  woman  was  dazed,  and 
at  no  time  w^as  she  herself  mentally.  It  is  to  be  remembered  in  this 
connection  that  the  interval  of  clear  consciousness  may  be  so  masked 
by  the  symptoms  of  concussion  as  to  be  completely  overlooked. 

Case  II. — An  open  depressed  fracture  of  the  skull. — Absence  of 
unconsciousness. — Paralysis  of  one-half  of  the  body.  —  Operation. — 
Recovery. 

This  case  illustrates  that  consciousness  may  be  unimpaired  following 
an  injury  to  the  head  severe  enough  to  cause  paralysis. 

A  boy,  nine  years  old,  was  struck  on  the  head  by  a  brick  falling  from 
a  height.  He  was  seen  immediately  after  the  injury  and  found  to  be 
conscious.       He   answered    questions   naturally.      There  was  a  large 


Fig.  25.— Case  1 1 .  Open  depressed  frac- 
ture of  the  skull :  X^  the  mid-point  be- 
tween glabella  and  inion ;  A,  middle  of 
depressed  bone. 


42 


INJURIES    TO    THE    HEAD 


scalp-wound  over  the  parietal  bone  and  a  little  anterior  to  the  parietal 
eminence  to  the  right  of  the  median  line.  The  bone  beneath  the 
scalp-wound  was  fractured  and  depressed  into  the  brain -substance. 
The  left  arm  and  the  left  leg  were  completely  paralyzed  to  motion. 
The  right  pupil  was  dilated  ;  sensation  was  present.  The  right  upper 
eyelid  drooped.  There  was  a  scar  in  the  right  cornea.  Immediately 
after  the  injury  the  temperature  was  96°  F.,  the  pulse  was  74,  the 
respiration  was  26.  When  examined  one  hour  after  the  accident  the 
pulse  had  fallen  to  68,  he  had  vomited  once,  and  had  been  somewhat 
nauseated. 

The  operation  of  elevation  of  the  depressed  fragments  of  bone  was 
done  under  ether.  The  fragments  of  bone  removed  were  about  the 
size  of  a  silver  half-dollar.     There  was  no  fissure  in  the  skull.     The 


Fig.  26. — Case  III. 


dura  mater  was  torn  and  the  brain  slightly  lacerated.  Upon  elevating 
and  removing  the  depressed  bone  hemorrhage  occurred  from  the  ves- 
sels of  the  dura  mater.  The  depressed  bone  was  not  replaced.  The 
dura  was  left  open  and  the  cavity  was  drained  by  a  wick  of  gauze, 
which  was  removed  upon  the  third  day. 

A  few  hours  after  the  operation  the  boy  was  perfectly  conscious  as 
before  the  etherization,  the  pupils  were  normal,  and  motion  had 
returned  in  the  paralyzed  limbs. 

Three  weeks  after  the  operation  a  small,  granulating  wound  remained 
and  there  was  a  slight  tendency  to  hernia  cerebri. 

Four  months  following  the  accident  the  boy's  condition  is  as  fol- 
lows :  The  wound  is  nearly  healed  and  continues  to  discharge  at  times. 
He  walks  naturally.  There  is  no  paralysis  of  arm  or  leg.  No  mental 
symptom  is  present. 


ILLUSTRATIVE    CASES  43 

The  interesting  and  unusual  fact  in  this  case  is  that  after  a  blow 
sufficiently  severe  to  cause  a  depressed  fracture  of  the  skull  and 
paralysis  of  one-half  of  the  body  the  patient  remained  conscious. 

The  exact  location  of  the  injury  to  the  head  and  brain  is  shown  in 

figure  25.  ■         J- 

Case' III. -/  /'Aw  upon  the  head.  —  Unconseiousness  wimediate. — 

Slight  bulging  of  right  eye.— Middle    meningeal  hemorrhage.— Frac- 
ture of  skull.  —  Operation. — Recovery. 

Examination  found  edema  of  the  right  temporal  region.  Uncon- 
sciousness present.  An  interval  of  consciousness  was  absent.  Slight 
bulging  of  the  right  eye. 

Operation  in  the  right  temporal  region.  A  skin-flap  was  made  over 
the  fracture  and  edematous  area.  A  fracture  was  detected  running 
from  about  the  middle  of  the  temporal  ridge  an  inch  back  of  the 
coronal  suture  outward  and  forward  across  the  squamous  part  of  the 
temporal  bone  to  a  half-inch  behind  the  pterion. 

The  bone  anteriorly  to  the  fracture  was  depressed.  The  trephine 
was  applied  over  the  depressed  portion  behind  the  coronal  suture. 
Upon  exposing  the  dura  no  pulsation  was  seen.  The  dura  was  dark 
in  color.  A  slight  amount  of  extradural  blood  escaped.  On  follow- 
ing the  fracture  down  to  the  base  of  the  skull  the  dura  was  found 
lacerated,  the  anterior  branch  of  the  middle  meningeal  artery  was 
torn,  and  blood-clot  and  lacerated  brain-tissue  were  present.  The 
anterior  branch  of  the  middle  meningeal  artery  was  tied  and  the 
hemorrhage  ceased.  The  blood-clots  were  removed,  the  exposed  area 
was  cleansed  with  boiled  water,  and  gauze  drainage  introduced.  All 
the  gauze  was  removed  in  four  days.  No  unusual  symptoms  attended 
convalescence.  Recovery  was  complete  in  three  months  (see  Fig.  26). 
This  case  is  of  interest  because  no  fracture  was  detected  before  the 
operation,  and  it  was  supposed  that  the  bulging  of  the  eye  indicated 
an  increase  of  intracranial  pressure,  which  proved  to  be  true. 

The  method  of  operating  was  comparatively  simple,  in  that  the 
fracture  was  followed  down  until  the  bleeding  vessel  was  found.  This 
necessitated  the  free  removal  of  bone  below  the  trephine  opening. 

There  was  no  interval  of  consciousness  in  this  case,  and  the  condi- 
tions found  easily  explained  its  absence.  The  man  was  suffering  from 
concussion  and  laceration  of  the  brain  as  well  as  from  intracranial 
pressure,  and  the  interval  of  consciousness  was  obscured  by  the 
presence  of  the  concussion.  The  recognition  of  an  interval  of  con- 
sciousness is  of  very  great  importance.  If,  however,  the  interval  of 
consciousness  is  not  present,  as  in  the  case  reported,  intracranial  pres- 
sure from  hemorrhage  can  not  be  said  to  be  absent,  for  concussion 
attendant  upon  the  injury  may  mask  the  interval  of  consciousness 
which  might  have  been  present  had  the  injury  been  less  severe. 


CHAPTER  II 
FRACTURES  OF  THE  BONES  OF  THE  FACE 

FRACTURES  OF  THE  NASAL  BONES 
Anatomy. — The  anatomical  relations  of  the  nasal  bones  (to 
the  perpendicular  plate  of  the  ethmoid,  the  vomer,  the  cartil- 
aginous septum,  the  superior  maxillary  bone,  and  the  frontal  bone) 
make  their  fracture  of  far  greater  importance  than  a  mere  super- 
ficial disfigurement  of  the  face  would  indicate  (see  Fig.  27).     The 

Vertical  ethmoid  plate. 


Frontal  sinus. 
Nasal  bone. 


Quadrilateral 
cartilage. 


Lower  lateral 
cartilage. 


,   Sphenoidal 
sinus. 


Vomer. 


Fig.  27. — Median  section  of  nose. 


site  of  the  fracture  is  usually  near  the  lower  edge  of  the  bone. 
Most  fractures  of  the  nasal  bone  are  open  through  either  the  skin 
or  the  mucous  membrane.  In  nearly  all  nasal  fractures  the  carti- 
lage of  the  septum  is  more  or  less  injured.  The  upper  lateral  car- 
tilages may  be  torn  from  their  attachments  to  the  nasal  bones, 
simulating  fracture  of  these  bones.  The  resulting  deformity  of 
this  accident  is  well  illustrated  in  figure  28.  A  high  fracture  of 
the  nasal  bones  with  lateral  deformity  is  shown  in  figure  30 :  the 
nasal  bone  of  one  side  has  been  impacted  with  the  frontal  bone, 

44 


FRACTURES  OF  THE  NASAL  BONES 


45 


Fig.  28. — Separation  of  cartilage  from  nasal 
bones  (Harrington). 


Fig.  29. — Fracture  and  lateral  displace- 
ment of  each  nasal  bone. 


Fig.  30.— Case  of  fracture  of  nasal  bones. 
Lateral  displacement  (Harrington). 


Fig.  31.— Fracture  and  lateral  displace- 
ment of  each  nasal  bone.  Side  view  of 
figure  29. 


46 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


and  the  nasofrontal  articulation  upon  the  opposite  side  has  been 
separated.  Figures  29  and  31  show  a  case  in  which,  bv  a  direct 
blow  squarely  upon  the  nasal  bones,  the  bones  were  separated 
and  one  was  laid  on  one  nasal  process  of  the  superior  maxillary 
bone  and  the  other  was  laid  upon  the  corresponding  bone.  The 
septum  was  intact,  as  is  shown  by  the  persistence  of  the  natural 
position  of  the  tip  of  the  nose.  Figures  32  and  33  show  a  syphilitic 
nose,  the  septum  gone,  and  the  nose  fallen  in.  The  contrast  in 
these  two  cases  is  instructive. 


Fig.  32.— Syphilitic  deformity  (Harrington).  Fig.  33.— Syphilitic  deformity  (same  case  as  Fig.  32). 


Symptoms. — Pain,  swelling,  crepitus,  and  deformity  are  usu- 
ally present.  The  subcutaneous  swelling  is  often  so  considerable 
as  to  obscure  deformity.  Gentle  pressure  is  often  sufficient  to 
detect  crepitus  in  this  fracture,  when  a  firm  grasp  determines 
little  or  nothing. 

Complications. — Through  infection  of  the  internal  or  the  ex- 
ternal wounds  suppuration  begins,  abscesses  form,  and  necrosis 
of  bone  and  liquefaction  of  cartilage  may  occur.  Emphysema 
may  be  noticed  if  the  fracture  is  open  into  the  nasal  cavity  (see 


THE  NASAL  SEPTUM  IN  FRACTURE  OF  THE  NOSE 


47 


Fig.  34).  It  will  disappear  after  a  few  days  untreated.  The 
lachrymal  duct  may  be  obstructed  if  the  nasal  process  of  the 
superior  maxillary  bone  is  involved.  The  nasal  bone  may  be 
forced  up  into  the  floor  of  the  anterior  fossa  of  the  skull,  and  cere- 
bral complications  arise  (see  Fig.  16).  If  the  deformity  following 
fracture  of  the  nasal  bones  is  not  corrected,  there  is  great  likeli- 


Fig.  34. — Case  of  open  fracture  of  the  nasal  bones.     Emphysema  over  the  forehead  and  the 

upper  part  of  the  face. 


hood  of  trouble,  either  immediately  or  in  after  years,  because  of 
damage  to  the  nasal  septum. 

The  Nasal  Septum  in  Fracture  of  the  N'ose  (see  Figs.  35,  36,  37, 
38,  39). — The  starting  of  the  quadrilateral  cartilage  of  the  septum 
at  some  of  its  bony  attachments  may  be  evident  at  once  after  the 
fracture  of  the  nose  as  a  marked  dislocation,  or  no  change  may  be 
seen  until  long  afterward,  when  a  ridge  due  to  inflammatory 
thickening  is  found  along  the  previously  loosened  border.     The 


48 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


septum  may  be  dislocated  from  its  attachment  to  the  superior 
maxilla,  and  deviate  into  one  nostril  or  the  other  like  a  curtain. 
The  commonest  dislocation  occurs  at  the  junction  of  the  cartilage 
of  the  septum  with  the  vomer  and  the  ethmoid. 

Lesions  of  the  septum  due  to  fracture  occur  usually  in  the  pos- 
terior two -thirds  of  the  cartilaginous  and  in  the  anterior  half  of  the 
bony  septum.  Fractures  rarely  extend  through  the  septum  to 
the  posterior  nares.  In  fractures  of  the  nasal  bones  with  little 
displacement  the  septum  may  show  no  changes.  Even  with 
considerable  depression  and  comminution  of  the  nasal  bones,  the 
septum  as  a  whole  may  appear  unchanged,  the  lesions  of  the  sep- 
tum being  confined  to  bowing  or  tearing  at  the  seat  of  fracture. 
When  the  nasal  bones  are  much  deviated,  the  free  edge  of  the 
septum  deviates  with  them.     Fractures  of  the  nasal  bones  may 


Fig-  35- 


Fig-  36-  Fig.  37.  Fig.  38. 

Figs.  35-39. — The  septum  in  fractures  of  the  nose  (Mosher). 


occur  alone  or  in  combination  with  fractures  of  the  septum. 
Severe  cases  of  broken  nose  usually  combine  the  two  conditions. 
Fractures  of  the  septum  which  admit  of  classification  follow  one  of 
two  types — horizontal  fractures  or  vertical  fractures.  The  verti- 
cal fracture  is  much  the  rarer.  It  may  occur  anywhere  in  the 
course  of  the  cartilaginous  septum,  but  when  situated  well  back, 
is  to  be  distinguished  from  dislocation  of  the  cartilage.  The  hori- 
zontal fracture  produces  a  gutter-like  deformity  roughly  parallel 
with  the  floor  of  the  nose.  The  convexity  appears  in  one  naris, 
the  concavity  in  the  other.  Closely  allied  to  these  last  two  frac- 
tures are  the  sigmoid  deviations,  in  which  the  relation  to  fracture 
is  unsettled.  They  are  so  common  that  they  are  mentioned  for 
the  sake  of  completeness.  The  name  describes  them.  They 
occur  in  the  same  two  types  as  the  Angular  variety. 


THE    NASAL    SEPTUM    IN    FRACTURE    OP    THE    NOSE 


49 


Treatment.— The  nasal  cavity  should  be  inspected  bv  mirror 
and  light  to  determine  any  lesion  of  the  septum.  Cocain  anes- 
thesia is  necessary  for  this  examination.  If  a  deviation  is  found, 
it  should  be  corrected  along  with  the  correction  of  the  external 
nasal  deformity.  For  this,  primary'  anesthesia  will  be  needed,  as 
the  manipulation  is  extremely  painful.  By  external  manipulation 
combined  with  elevation  of  the  fragments  and  internal  pressure 
with  Roe's  elevator  (see  Fig.  40)  the  deformity  usually  can  be  over- 
come. Any  strong,  narrow,  and  thin  instrument  will  be  of  service 
as  an  elevator.     For  fractures  high  up  with  displacement,  gauze 


Fig.  40. — Fracture  of  nasal  bones.     Elevation  of  depressed  bone  by  instrument  introduced 

into  the  nostril. 


packing  carried  w'ell  up  will  be  required  to  retain  the  elevated 
bones.  For  lower  deviations  the  Asch  tube  will  be  needed.  If  the 
nose  is  crushed,  it  will  be  necessar\^  to  model  the  nose  over  the 
Asch  tube,  one  being  placed  in  each  nostril  to  preserve  the  con- 
tour and  lumen  of  the  nose.  If  there  is  no  tendency  for  the  de- 
formity to  recur,  the  use  of  splints  is  not  indicated.  Care  must 
be  exercised  to  avoid  sudden  pressure  on  the  nose  from  the  rough 
use  of  the  pocket  handkerchief.  In  the  treatment  of  these  cases 
special  cleanliness,  perfect  drainage,  and  frequent  dressings  are 
important.  If  there  is  a  recurrence  of  the  external  deformity, 
4 


50 


FRACTURES    OF    THE    BONES    OF    THE    FACE 


localized  pressure  may  be  exerted  in  various  wavs,  all  of  which 
are  more  or  less  unsatisfactorv. 

The  tin  splint  fixed  to  the  forehead  by  a  circular  plaster  band 
is  of  service.  This  tin  splint  (see  Fig.  41),  made  from  ordinary 
sheet  tin,  consists  of  a  forehead  and  a  nasal  portion.  The  nasal 
portion  may  be  twisted  or  bent  laterally  to  secure  the  desired 
pressure  upon  the  nose,  the  counterpressure  being  obtained 
through  the  fixation  secured  by  the  adhesive  plaster  band.  Re- 
peated adjustments  of  this  splint  are  needed  to  make  the  splint  of 
continued  efliciencv  ;  with  all  care,  however, 
the  tin  splint  is  not  generally  eft'ective. 

The  use  of  adhesive  plaster  strips  (after 
Davis)  from  cheek  or  malar  bone  to  nose 
with  small  compresses  is  of  limited  value. 

Cobb's  nasal  splint,  shown  in  figure  42,  is 
expensive,  but  is  very  satisfactory  for  mak- 
ing direct  pressure  upon  the  nasal  bones. 
The  splint  is  made  of  a  band  of  steel,  fitted 
to  the  head  like  the  hat-band  of  a  hat.  To 
this  band  are  attached  an  arm  and  a  pad 
with  screw  adjustment.  A  strap  OA'er  the 
head  and  one  beneath  the  chin  prevent 
downward  and  upward  displacement. 

Coolidge's  Splint  (see  Fig.  43). — This 
consists  of  a  tin  pad  for  the  forehead  with 
strap  encircling  the  forehead  for  the  reten- 
tion of  the  pad  in  position.  To  the  lower  border  of  the  pad  are 
soldered  two  wire  arms  upon  which  slide  two  small  felt  pads.  The 
arms  can  be  bent  so  that  counterpressure  may  be  obtained  upon 
the  firm  parts  of  the  face,  while  direct  pressure  with  the  other  pad 
is  brought  to  bear  upon  the  nose.  This  splint  is  inexpensi^-e  and 
is  efficient. 

The  nasal  cavity  should  be  cleansed  at  least  twice  daily  with 
antiseptic  douches.  Seiler's  tablets,  one  tablet  dissolved  in  a 
quarter  of  a  tumbler  of  warm  water,  used  with  the  Birmingham 
glass  douche,  make  a  satisfactory  wash.  The  external  wounds 
should  be  dressed  according  to  general  surgical  principles.  It  is 
well  to  remember  in  this  connection  that  suppurating  wounds  do 


Fig.  41. — Fracture  of 
nasal  bones.  Tin  nose- 
splint  applied. 


THE  NASAL  SEPTUM  IN  FRACTURE  OK  THE  NOSE      5 1 

far  better  if  dressed  frequently  than  if  left  to  accumulate  purulent 
discharges. 

After  a  l)l()\v  upon  the  nose,  even  if  there  is  no  immediate  de- 
formity, the  nose  should  be  examined  to  determine  the  presence 
of  swelling  upon  the  cartilaginous  septum.  Even  a  slight  blow 
upon  the  nose  may  cause  a  hematoma  of  the  cartilaginous  septum 
(see  Fig.  44).  This  hematoma  is  liable  to  become  infected  and 
to  suppurate.  Considerable  destruction  of  cartilage  may  follow, 
resulting:  in  marked  disfigurement  of  the  nose. 


Fig.  42.— Cobb's  splint  applied  to  a  case  of  fracture  of  the  nose.     The  head-band  is  so  adapted 
to  the  shape  of  the  head  that  it  remains  fixed  and  offers  a  point  of  counterpressure. 


The  involvement  of  the  base  of  the  skull  adds  a  serious  element 
to  an  ordinary  simple  accident  (see  Figs.  16,  18). 

The  prognosis  as  regards  the  resulting  deformity  must  always 
be  guarded.  Union  usually  takes  place  within  two  weeks  of  the 
accident  and  is  firm  in  one  month.  In  treating  fracture  of  the 
nose  it  is  important  to  be  ever  mindful  of  hematoma  of  the  septum, 
and  of  abscess  of  the  septum  resulting  from  the  hematoma.  The 
external  deformity  that  follows  fracture  does  not  tend  to  increase, 
but  the  internal  deformity  does.  It  is,  therefore,  of  even  more 
importance  to  correct  the  internal  deformity  than  the  external. 
Unless  both  are  corrected,  the  nose  mav  be  straight  but  obstructed. 


52 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


FRACTURES  OF  THE  MALAR  BONE 
Examination, — Palpation    of    the    malar    bone    is    somewhat 
difHcult.     The  best  method  of  doing  it  is  to  stand  behind  the 
sitting  patient  (see  Fig.  45),  and  to  feel  both  malar  bones  at  the 


Fig.  43. — Coolidge's  nasal  splint:  a,  Forehead  plate;  b,  pad;  c,  screw  controlling  position  of 

pad  ;  li,  head-strap. 


7* 


Fig.  44. — Hematoma  of  the  nasal  septum  (after  Roe). 


same  time — the  left  one  with  the  left  hand,  the  right  one  with 
the  right  hand.  The  malar  process  of  the  superior  maxilla  is 
felt  inferiorly  by  pushing  the  skin  of  the  cheek  upward.  The 
orbital  part  of  this  process  is  felt  superiorly  at  the  middle  of  the 
inferior  border  of  the  orbit.     Following  the  orbital  margin  out- 


FRACTURES  OF  THE  MALAR  BONE 


53 


ward  and  upward,  the  orbital  border  is  palpated  up  to  the  frontal 
process.  Following  the  malar  process  of  the  superior  maxilla 
backward,  the  free  inferior  border  of  the  malar  is  felt  continuous 
backward  with  the  zygomatic  process.  vStarting  on  the  frontal 
process,  the  posterior  border  of  the  malar  may  be  palpated  down- 
ward and  backward  to  the  upper  border  of  the  zygomatic  process 
of  the  temporal  bone.  The  inferior  surface  of  the  malar  may  be 
felt  by  placing  the  fingers,  palm  upward,  in  the  superior  sulcus  of 
the  cheek  and  following  backward  until  the  coronoid  process  of 
the  lower  jaw  is  felt.     In  the  case  of  a  fracture  that  is  as  often 


Fig.  45. — Proper  position  from  which  to  palpate  the  malar  bones.     The  fingers  touch  the 
inferior  borders,  the  thumbs  the  posterior  borders,  of  the  malar  bones. 


unrecognized  as  is  this  one  it  is  important  to  be  ven.'  familiar  with 
the  details  of  the  outline  of  the  bone. 

Symptoms. — Fracture  of  the  malar  bone  is  caused  by  a  severe 
blow  upon  the  cheek.  It  is  rather  unusual  to  find  a  fracture  of 
the  body  of  the  bone.  More  often  there  is  a  fracture  of  one  of  its 
processes,  the  line  of  fracture  being  continuous  with  a  fracture  of 
some  adjoining  bone.  The  malar  is  depressed  as  a  whole,  or  tilted 
inward  toward  the  zygomatic  fossa  because  of  a  loosening  of  one 
or  more  of  its  articulations  or  because  of  a  fracture  or  crushing 
of  the  superior  maxilla.  The  deformity  consists  of  a  depression 
to  the  outer  side  of  and  below  the  eye.  The  line  of  fracture  or 
separation  can  sometimes  be  palpated.  ^Mobility  and  crepitus 
are  rarely  obtained.     If  the  depression  of  the  malar  or  of  an  asso- 


Fig.  46. — Depressed  fracture  of  the  left  malar  bone.     Note  swelling  of  the  left  cheek  and  slight 
hollow  outside  left  orbit  (Warren). 


Fig.  47. — Depressed  left  malar  bone.     Same  case  as  figure  46.     Note  depression  behind  and 
below  left  orbit  (Warren). 


54 


FRACTURES  OF  THE  MALAR  BONE 


55 


ciatcd  fracture  of  the  zygomatic  arch  impinges  upon  the  space  in 
whicli  the  coronoid  process  nio\-es  in  the  opening  of  the  mouth, 
the  motions  of  the  lower  jaw  will  be  restricted  (see  Fig.  48).  The 
limitation  of  motion  of  the  lower  jaw  may  be  temporary  or  per- 
manent, depending  upon  whether  it  is  due  to  hemorrhage  and 
swelling  or  bony  pressure.  The  coronoid  process  of  the  lower 
jaw  may  be  fractured  by  the  same  force  which  fractured  the 
zygoma  or  malar.  Localized  subconjunctival  hemorrhage  may 
appear  if  the  orbit  is  involved.     If  the  floor  of  the  orbit  is  frac- 


Articular  pro- 
cess of  infer- 
ior maxilla. 


Coronoid  pro- 
cess of  infer- 
ior maxilla. 


Fig.  48. — Note  relations  of  coronoid  of  inferior  maxilla  to  zygomatic  process  and  malar  bones ; 
the  space  on  either  side  of  the  coronoid  process  is  filled  by  muscle. 


tured  so  that  the  infra-orbital  nerv^e  is  implicated,  there  will  ap- 
pear prickling  sensations  throughout  the  area  of  distribution  of 
that  nerve — namely,  along  the  upper  gum,  the  skin  of  the  cheek, 
of  the  nose  and  of  the  upper  lip. 

Treatment. — It  is  oftentimes  impossible  completely  to  correct 
the  deformity  except  by  operative  means.  If  any  interference 
with  the  movements  of  the  lower  jaw  persists  after  the  acute  swell- 
ing disappears, — that  is,  after  two  weeks, — or  if  it  is  very  evident 
at  the  outset  that  the  limitation  of  motion  is  due  to  the  depression 
of  bone,  then  operative  interference  is  demanded.     Before  a  cut- 


56  FRACTURES    OF    THE    BONES    OF    THE    FACE 

ting  Operation  is  resorted  to  an  anesthetic  should  be  administered 
and  an  attempt  made  by  pressure  with  a  blunt  instrument  under 
the  malar  from  inside  the  cheek  to  raise  the  depressed  fragment. 
If  this  can  not  be  effected,  a  small  incision  should  be  made  at 
the  most  advantageous  point,  avoiding  making  the  fracture  an 
open  one.  Through  this  incision  access  is  gained  directly  to  the 
bone.  By  means  of  a  narrow  periosteum  elevator,  retractor, 
hook,  or  a  screw  elevator,  the  fragment  can  be  raised  into  its  nor- 
mal position. 

Union  occurs  in  two  weeks.  There  is  no  tendency  to  a  recur- 
rence of  deformity,  therefore  no  retentive  apparatus  is  necessary. 

The  surgeon  is  not  uncommonly  asked  to  remove  the  slight 
depression  attending  a  healed  fracture  of  the  malar  bone.  This 
may  be  most  difficult.  It  should  be  attempted,  however,  as  in 
fresh  injuries,  without  a  cutting  operation,  or  by  an  incision  within 
the  mouth  through  the  mucous  membrane,  or,  if  necessary,  by 
an  external  incision. 


FRACTURE  OF  THE  SUPERIOR  MAXILLA 

Fracture  of  the  superior  maxilla  occurs  so  frequently  from  a 
bicycle  injury  that  it  may  properly  be  called  the  bicycle  accident. 
The  blow  causing  this  fracture  is  usually  not  in  the  direction  to 
damage  the  base  of  the  skull,  but  to  tear  the  bones  of  the  face. 
The  nasal  process  of  the  superior  maxilla  may  be  broken  when 
the  nasal  bone  is  fractured.  The  anterior  wall  of  the  antrum  may 
be  broken  by  the  same  blow.  The  alveolar  process  may  be  broken. 
The  damage  to  the  bones  of  the  face,  and  particularly  to  the  upper 
jaw,  is  associated  with  injuries  to  various  contiguous  bones. 
Blows  result  in  many  irregularly  disposed  fractures. 

The  diagnosis  is  made  by  inspecting  the  mouth,  nose,  and 
cheek.  These  fractures  being  open,  there  is  little  difficulty  in 
detecting  them.  A  very  careful  inspection  should  be  made,  with 
an  anesthetic  if  necessary,  to  determine  the  extent  of  the  lesions. 
Emphysema  and  great  swelling  of  the  face  occur.  There  may  be 
no  wound  of  the  skin.  Whether  the  injury  to  the  upper  jaw  is 
associated  with  injury  to  the  base  of  the  skull  or  not  can  be  deter- 
mined in  the  absence  of  visible  signs  by  the  subsequent  develop- 


I'RACTURl'S    OF    THE    SUPERIOR    MAXILLA  57 

ment  of  cerebral  symploms.  Necrosis  of  bils  of  bone  is  rare  after 
upper-jaw  fractures,  excepting  fracture  of  the  alveolar  border. 
Hemorrhage  may  be  considerable,  but  it  is  easily  controlled  by 
pressure.  The  infra-orbital  nerve  may  be  damaged.  The  lachry- 
mal canal  mav  be  temporarily  compressed  or  obliterated. 

Treatment. — If  there  is  no  wound  of  the  skin  and  much  de- 
pression of  the  jaw,  so  that  the  face  is  knocked  in,  it  will  be 
necessary  to  devise  some  method  of  elevating  the  depressed  bone 
and  of  restoring  the  normal  contour  of  the  face.  To  avoid  a 
visible  scar,  the  mucous  membrane  should  be  incised  on  the  inner 
side  of  the  upper  lip,  and  the  fragments  elevated  by  an  instru- 
ment introduced  through  the  incision.  As  little  bone  as  possible 
should  be  removed,  so  as  to  leave  sufficient  support  to  the  soft 
parts  of  the  cheek  after  healing.  Only  thus  can  a  falling  in  of 
the  cheek  be  prevented.  If  access  through  the  mouth  is  unsuc- 
cessful, it  may  be  necessary  to  incise  the  skin  over  the  fracture. 
This,  of  course,  is  to  be  avoided  if  possible.  The  accidental  wounds 
should  be  thoroughly  and  vigorously  swabbed  with  a  solution  of 
corrosive  sublimate  (i  :  5000).  The  use  of  tiny  swabs  of  gauze 
held  by  forceps  w411  facilitate  this  procedure.  The  avoidance  of 
sepsis  in  these  cases  is  of  paramount  importance.  If  the  wounds 
become  septic,  there  is  great  danger  of  an  extension  of  the  inflam- 
matory process  to  the  deeper  parts  or  even  to  the  meninges  of  the 
brain.  Lacerations  of  the  soft  parts — lips  and  cheeks — ma}' 
have  their  edges  approximated  to  secure  less  scar  than  if  left 
unsutured.  Loose  small  bits  of  bone  should  be  removed  with 
forceps  and  scissors.  Loosened  teeth  should  be  left  in  good  posi- 
tion in  their  sockets.  A  mold  of  the  lower  jaw  should  be  taken 
in  composition  or  plaster-of- Paris,  if  possible,  by  a  competent 
dentist,  and  a  rubber  splint  made  from  this  mold  to  fit  the  teeth 
and  alveolar  border  of  the  lower  jaw.  When  this  splint  is  applied, 
its  upper  surface  may  be  brought  up  against  the  teeth  of  the  upper 
jaw  and  held  snugly  in  apposition  by  an  external  bandage,  as  in 
fracture  of  the  lower  jaw.  This  splint  will  materially  assist  in 
reducing  the  displacement  of  the  upper-jaw  fragments.  It  may 
be  possible  for  a  dentist  to  apply  a  splint  directly  to  the  alveolar 
margin  and  teeth  of  the  upper  jaw^  If  this  is  possible,  greater 
securitv  of  fragments  will  be  obtained  than  by  any  other  method 


58  FRACTURES  OF  THE)  BONES  OF  THE  FACE 

of  treatment.  The  physician  may  greatly  assist  in  immobiHzing 
the  fracture,  until  a  permanent  dressing  is  applied,  by  making 
quickly  a  temporary  splint  of  dental  wax  or  dental  composition, 
and  applying  it  to  the  teeth  and  alveolar  margin  of  the  upper  jaw. 
This  composition  is  softened  and  made  malleable  by  placing  it  in 
hot  water ;  it  can  then  be  molded  on  the  jaw,  and  in  two  or  three 
minutes  is  firm  (see  Fracture  of  the  Lower  Jaw) . 

After  Care. — Six  weeks  to  two  months  will  be  necessary  to 
insure  firm  union  and  freedom  from  complications.  The  swelling 
associated  with  the  reparative  process  will  gradually  subside. 
Great  care  must  be  exercised  in  the  nursing  of  the  patient  after 
this  injury,  as  the  element  of  shock  is  an  important  one  to  be 
considered.  Strychnin  sulphate  (-g'^  of  a  grain),  given  two  or 
three  times  daily,  is  indicated  if  there  is  evidence  of  shock  following 
the  accident.  This  should  be  continued  each  day  for  as  long  a 
period  as  shock  is  evident. 

Proper  nourishment  under  these  adverse  conditions  of  adminis- 
tration is  to  be  given  careful  consideration.  Liquids  alone  are 
to  be  used  the  first  week.  These  may  be  given  by  enemata  or  by 
the  mouth  with  a  tube  to  the  back  of  the  pharynx  or  by  a  nasal 
tube  if  necessary.  Nasal  feeding  is  simply  and  easily  carried 
out.  A  rubber  tube  three  feet  long  is  needed,  to  one  end  of  which 
is  attached  a  funnel  and  to  the  other  end  a  soft-rubber  catheter, 
in  size  No.  lo  F.  The  patient  is  half  reclining  while  the  surgeon 
introduces  the  catheter  into  the  nose  until  it  passes  well  back  and 
down  into  the  pharynx.  The  funnel,  somewhat  elevated  a  foot 
or  more  above  the  patient's  head,  is  kept  filled  with  the  liquid 
nourishment  so  that  its  contents  run  slowly  into  the  esophagus. 
A  plug  of  absorbent  cotton,  moistened  with  a  four  per  cent,  cocain 
solution,  and  placed  in  the  nose  for  a  few  minutes  before  feeding, 
facilitates  this  procedure. 

The  nose  and  mouth  should  be  douched  and  swabbed  regularly 
each  day.  This  should  be  done  after  feeding  the  patient,  and 
oftener  if  necessary  in  order  to  avoid  all  odor  from  the  mouth. 
Listerin,  two  teaspoonfuls  to  half  a  cup  of  water,  is  a  satisfactory 
wash  for  this  purpose.  The  profuse  dribbling  of  saliva  which 
attends  this  fracture  demands  drainage  of  the  mouth  by  wicks  of 
gauze  placed  in  the  cheeks  and  gauze  handkerchiefs  for  keeping 


KRACTURlvS   OF   THE    INFERIOR    MAXILLA 


59 


the  surrounding  parts  dry.  Wiring  the  fragments  of  bone  may  be 
necessary  if  there  is  great  displacement.  Wiring  the  alveolar 
border  to  the  bod>-  of  the  jaw  may  be  demanded.  vSuture  of  the 
bony  fragments  with  chromicized  catgut  will  often  steady  them  in 
position  until  union  takes  place. 


FRACTURES  OF  THE  INFERIOR  MAXILLA 
With  the  exception  of  the  superior  internal  surface  of  the  artic- 
ular process,  practically  the  whole  of  the  inferior  maxilla  may  be 
palpated.     Fractures  of  the  inferior  maxilla  are  caused  by  direct 


Fig.  49.— Fracture  of  the  inferior  maxilla 
(interdental  splint)  (X-ray  tracing). 


pig_  50.— Fracture  of  the  inferior  max- 
illa in  two  places.  Alinement  of  teeth  per- 
fect (X-ray  tracing). 


violence.  The  seat  of  the  fracture  will  be  determined  by  the  force 
and  direction  of  the  blow,  by  the  location  of  the  teeth  in  the  jaw 
(the  jaw  being  weakest  where  the  teeth  have  been  lost),  by  the 
presence  of  any  foreign  body  between  the  teeth  (such  as  a  pipe), 
and  by  the  presence  or  absence  of  muscular  relaxation.  Fractures 
of  the  base  of  the  skull  through  blows  on  the  jaw  are  more  likely  to 
occur  if  the  mouth  is  open.  Fractures  of  the  body  of  the  bone  are 
common ;  of  the  ramus  behind  the  molar  teeth,  rather  uncommon ; 
of  the  condyloid  and  coronoid  processes,  very  uncommon.  The 
seats  of  fracture  of  the  inferior  maxilla  are  shown  in  the  accom- 
panying illustrations  (see  Figs.  49,  50,  51.  5^)- 


6o 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


Excepting  those  of  the  condyloid  and  coronoid  processes,  frac- 
tures of  the  inferior  maxilla  almost  always  open  into  the  mouth. 
They  occasionally  open  through  both  the 
mucous  membrane  and  the  skin. 

Examination. — Even  when  the  patient 
can  not  open  the  mouth  sufficiently  to 
admit  the  examining  finger,  palpation  of 
the  body  and  ramus  of  the  jaw,  with  one 
finger  in  the  cheek  and  another  finger  upon 
the  chin,  will  often  reveal  the  seat  of  frac- 
ture. 

Symptoms. —  Pain,  crepitus,  and  ab- 
normal mobility  may  be  present.  Immedi- 
ate swelling  of  the  gum  appears  at  the  seat 
of  the  fracture.  Teeth  contiguous  to  the  fracture  of  the  body  of 
the  maxilla  will  be  either  displaced  or  loosened.  The  displacement 
of  the  fragments  in  fracture  of  the  body  and  ramus  will  be  most 


Fig.  51. — Fracture  of 
the  inner  side  of  the  alveo- 
lar process,  from  a  force 
applied  to  teeth. 


Fig.  52.— Fracture  of  the  lower  jaw,  showing  loss  cf  alinement  of  teeth. 


easily  detected  by  noticing  the  differences  in  level  of  the  teeth  on 
each  side  of  the  fracture  (see  Fig.  52).     The  face  appears  swollen. 


FRACTURHS    OF    Tlllv    INFERIOR    MAXILLA 


6i 


After  a  few  days  the  submaxillary  and  adjoining  cervical  1\  nipli- 
atic  glands  become  enlarged.  The  salivary  secretions  are  increased 
in  quantity,  and  because  of  the  disinclination  to  painful  swallow- 
ing, the  saliva  dribbles  out  of  the  mouth.  If  the  fracture  opens 
into  the  mouth,  suppuration  often  appears  and  pus  mingles  with 
the  saliva.  Particles  of  decomposing  food  between  the  teeth  and 
in  the  spaces  outside  the  jaw  within  the  cheeks  add  to  the  bacte- 
rial pabulum.  The  odor  from  this  mass  of  foul  material  is  char- 
acteristically penetrating"  and  offensive.  After  a  few  weeks 
necrosis  of  bone  may  occur  at  the  seat  of  fracture,  with  abscess 
formation.     A  discharging  sinus  pointing  to  the  disease  appears. 


Fig.  53. — Aluminium  splint  to  be  placed  on  teeth.     For  closed  fracture,  a  continuous  capping 
of  gold  or  aluminium  or  other  metal  cemented  upon  the  teeth. 


These  cervical  abscesses,  often  diflficult  to  manage,  occupy  the 
region  of  the  body  of  the  jaw.  The  submaxillary  and  upper 
carotid  triangles  may  be  filled  by  a  brawny  infiltration  associated 
with  necrosis  of  a  fractured  jaw.  On  the  other  hand,  with  proper 
treatment  and  in  less  difficult  cases  the  course  of  the  healing  pro- 
cess is  simple  and  of  easy  management.  Suppuration  is  pre- 
vented. There  is  no  necrosis,  and  the  repair  of  the  fracture  takes 
place  unhindered. 

Treatment. — The  primary  object  of  treatment  is  the  preser- 
vation of  the  natural  alinement  of  the  teeth.  This  object  is 
attained  by  a  complete  reduction  of  the  fragments  of  the  fractured 


62 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


bone.  If  a  tooth  interferes  with  the  perfectly  accurate  closure  of 
the  mouth,  and  if  the  adjustment  of  the  fragments  is  prevented 
by  the  position  of  the  tooth,  it  should  be  extracted  at  once. 
Ordinarily,  there  is  but  slight  displacement.  This  displacement 
can  be  corrected  by  digital  pressure  upon  both  fragments. 

Fracture  of  the  Body  of  the  Jaw. — The  simple  fracture  of  the 
body  of  the  jaw  without  much  displacement  may  be  temporarily 
treated  by  the  four-tailed  bandage,  which  should  hold  the  teeth 
of  the  lower  jaw  closely  in  apposition  with  the  corresponding  teeth 
of  the  unbroken  upper  jaw.     As  soon  as   practicable,  a   dental 


Fig.  54.— Four-tailed  bandage  for  fractured  jaw. 


Splint  of  rubber  or  aluminium  should  be  made  and  applied  by  a 
dentist.  This  aluminium  splint  fits  the  crowns  of  the  teeth  some 
distance  upon  each  side  of  the  fracture,  and  holds  the  fragments 
firmly  in  apposition  (see  Fig.  53).  It  also  permits  of  opening  and 
shutting  the  mouth.  The  old-time  four-tailed  bandage  and  extra- 
dental  splint  of  millboard  (see  Fig.  54)  is  inefficient.  As  a  per- 
manent dressing  it  should  be  discarded.  It  is  useful  only  as  a 
temporary  support.  In  the  simple  cases,  in  the  absence  of  a  com- 
petent dentist  to  make  the  aluminium  or  rubber  dental  splint,  a 
splint  of  silver  wire  passed  around  many  teeth  upon  each  side  of 
the  seat  of  fracture  is  often  efficient.     The  method  of  wiring  two 


FRACTURE  OF  THI-  BODY  OF  THE  JAW 


63 


adioining  teelh,  those  on  each  side  the  fracture,  is  unsatisfactor>' 
in  that  the  strain  loosens  the  teeth  and  displacement  is  easily 
effected  (see  Fig.  55). 


Ficr.  =;;.— Fracture  o''  the  lower  jaw.    Wiring  with  silver  wire. 


Pig.  56.— Hard-rubber  splint,  with  arms  anu  posl-rior  strap. 

Fracture  of  the  body  toward  the  angle  of  the  jaw.  through  the 
region  of  the  molar  teeth,  is  often  less  easily  held  in  good  position. 
To  the  dental  rubber  splint  the  dentist  should  add  lateral  arms  of 


64 


FRACTURES   OF   THE   BONES   OF   THE   FACE 


wire,  held  in  position  by  a  posterior  strap  (see  Fig.  56).     These 
wire  arms  increase  the  efficiency  of  the  dental  splint,  for  a  band- 


Fig.  57.— Hard-rubber  splint,  with  arms  and  bandage,  applied.     Similar  to  figure  56  (Moriarty) . 


pjg_  jg. — Hard-rubber  splint ;  wire  arms  and  chin-piece  held  together  bj'  metal  rods  and  nuts. 


age  is  passed  under  the  chin  between  the  wires  and  thus  steadies 
the  jaw  by  upward  pressure  (see  Fig.  57).  If  a  still  more  efficient 
method  is  demanded,  the  dentist  uses  an  extradental  chin-piece 


FRACTURE  OF  THE  BODY  OF  THE  JAW 


65 


Fig.  59.— Same  splint  as  seen  in  figure  5S ;  superior  view. 


Fig.  60.— Front  view  of  splint  (figure  58)  with  mouth  closed  (Moriarty). 
5 


66 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


Fig.  6i. — Side  view  of  splint  (figure  5S)  ;  arms  and  chin-piece  in  position  (Moriarty). 


Fig.  62. — Splint  similar  to  figure  5S.     Mouth  maybe  opened  without  impairing  efficiency  of 

splint  (Moriarty). 


THE    MAKING    OF    THE    DENTAL    SPI.IXT 


67 


of  metal  (see  Fig.  58),  which  is  adjusled  by  screws  so  that  firm, 
evenly  graduated  pressure  upon  the  fractured  jaw  is  maintained 
between  the  inside  denial  sj^lint  and  the  outside  chin-piece. 
While  wearing  this  s])Iint  the  mouth  can  be  opened  easily  (see 
Figs.  60,  61,  62). 

The  Makiiiy  of  the  Dental  Spli)tt. — If  an  impression  is  desired 
of  the  crowns  of  the  teeth  and  the  adjoining  gum,  it  is  best  made 
by  using  the  modeling  composition  manufactured  for  the  use  of 
dentists.  The  necessary  amount  of  the  composition  is  dropped 
into  hot  water;  when  soft,  the  composition  is  put  into  the  metal 


Fig.  63. — Modeling-  cups  :  A,  Used  for  the  upper  jaw  ;  B,  used  for  the  lower  jaw. 


impression-cups  (see  Fig.  63).  The  surface  of  the  composition  is 
warmed  by  holding  it  over  a  flame  or  holding  it  again  in  hot  water ; 
then  the  impression-cup  containing  the  softened  composition  is 
placed  in  the  mouth  and  the  impression  made.  Immediately  upon 
the  removal  of  the  mold  from  the  mouth  the  composition  cools 
and  hardens.  From  this  mold  is  made  the  duplicate  of  the  alveo  - 
lar  border  and  the  teeth  in  plaster-of- Paris  (see  Fig.  64).  The 
lines  of  fracture  are  clearly  indicated  upon  the  plaster  cast,  ^^'ith 
a  fine  saw  the  cast  is  cut  upon  these  lines  and  the  lower  teeth  are 
articulated  with  the  plaster  cast  of  the  upper  jaw,  which  has  been 


Fig.  64. — Plaster  cast  of  fracture  of  the 
jaw. 


Fig.  65. — Plaster  cast  of  lower  jaw  articu- 
lating with  upper  jaw. 


Fig.  66.— Simple  vulcanite  splint,  with  boxes  vulcanized  on  each  side  (Moriarty). 


Fig.  67.— Hard-rubber  splint  in  position,  upper  teeth  resting  upon  it  (Moriarty). 


TREATMKNT 


69 


made.  Plaster  cream  is  used  to  hold  the  sawed  portions  to- 
gether. In  other  words,  the  fracture  has  been  reproduced  and 
reduced  in  plaster-of- Paris.  Both  upper  and  lower  casts  are  then 
put  upon  an  articulator  (see  Fig.  65).  A  vulcanite  splint  is  made 
from  this  reconstructed  lower  jaw,  and  when  this  is  applied  to  the 
fractured  jaw  as  an  interdental  splint,  the  deformity  is  corrected 
and  comfortably  prevented  from  recurring  (see  Figs.  66,  67). 

Fraciitre  of  the  Ramus  of  ihe  Inferior  Maxilla  Just  Behind  the 
Molar  Teeth. — The  displacement  is  difficult  to  correct.  The  frac- 
ture is  usually  oblique  from  before  backward  and  downward,  as 
seen  in  the  tracing   (see  Fig.   50).     The  body  of  the  jaw  drops 


Fig.  68.— Interdental  splint  used  in  fracture  of  the  jaw  when  no  teeth  exist  in  upper  alveolar 

arch  (after  Moriarty). 


downward  and  backward  and  the  ramus  slides  forward.  No  den- 
tal splint  is  practicable,  because  there  are  no  teeth  on  one  side  of 
the  fracture  to  w^hich  the  splint  could  be  attached.  Etherization 
will  often  be  found  helpful,  and  at  times  necessar}",  in  the  reduc- 
tion of  this  deformity.  Reduction  is  accomplished  by  pressure 
backward  upon  the  ramus  with  the  thumb  in  the  mouth  and  a 
simultaneous  lifting  forward  and  upward  of  the  body  of  the  jaw. 
Reduction  is  maintained  by  an  outside  pad  and  metal  chin-piece 
and  a  buckle  and  strap  splint.  This  buckle  and  strap  splint  (see 
Fig.  69)  is  of  great  advantage  because  it  is  easily  adjusted,  and 
the  amount  of  pressure  can  be  graduated.     It  is  of  importance  to 


70 


FRACTURES  OF  THE  BONES  OF  THE  FACE 


note  here  that  even  after  this  fracture  has  been  reduced  and  is  at 
the  outset  apparently  held  reduced  by  the  bandage,  yet  it  will 
usually  slump  away  a  little  and  at  the  end  of  the  first  twenty-four 
hours  after  setting  the  fracture  the  fragments  will  be  found  to  be 
partially  unreduced.  Upon  a  second  application  of  pressure  by 
tightening  the  bandage  the  fragments  will  come  into  apposition 
with  comparative  ease.  By  careful  and  repeated  adjustments 
of  the  bandage  and  padding,  after  a  week  and  a  half  even  in  the 
most  obstinate  cases,  the  jaw  will  be  found  to  be  in  good  position, 
with  the  teeth  articulating. 

Fracture  of  the  Body  of  the  Ratnus  upon  the  Savie  or  Opposite 
Sides  of  the  Inferior  Maxilla. — The  fracture  is  difficult  to  hold 


Fig.  69.- 


-Molded  leather  chin-piece  with  buckles  and  straps  for  graduated  pressure  upon 
a  fracture  of  the  inferior  maxilla  (after  Moriarty). 


fixed.  In  this  case  the  dental  aluminium  or  rubber  splint  will  be 
needed,  together  with  the  outside  pressure  made  by  the  metal 
chin-piece. 

Whichever  method  of  treatment  is  adopted,  the  fracture  at 
first  should  be  inspected  daily  in  order  to  insure  accurate  adjust- 
ment of  apparatus.  The  mouth  and  teeth  should  be  kept  scrup- 
ulously clean.  When  practicable,  the  teeth  should  be  scaled  by  a 
dentist  before  permanent  apparatus  is  applied.  Brush  and  swab 
with  some  mild  antiseptic  wash,  such  as  Listerin,  one  part  in  four 
of  water,  should  be  used  after  taking  nourishment  and  before  bed- 
time and  upon  rising  in  the  morning.     The  liquid  nourishment  of 


TRIvATMUNT  7 1 

the  patient  sliduld  he-  ,i;i\(.n  llu'diii^li  a  j^lass  IuIk'  at  lirst.  If  it  is 
unwise  to  o])c'ii  the  nioutli,  a  ruhbcr  catheter  nia\-  he  used  behind 
the  molar  teeth.  'I'he  rul)I)er  catlieter  with  a  si])hon  attached  is  a 
very  satisfactory  method  of  feeding.  The  general  health  should 
receive  careful  attention.  A  patient  with  this  fracture  is  apt  to 
beconu"  despondent  and  anxious  about  himself,  ])artieularly  if 
suppuration  exists.  The  repeated  swallowing  of  foul  secretions 
impairs  the  appetite,  causes  indigestion  and  generally  poor  health. 
The  loss  of  variety  in  diet  favors  this  condition.  Out-of-door 
exercise,  plent\-  of  sleep,  a  mild  tonic,  such  as  ferrated  elixir  cali- 


Fig.  70.— If  no  lower  teeth  exist,  the  artificial  teeth  may  be  utilized,  as  seen  above,  as  a 
splint.  Boxes  seen  on  sides  of  plate,  to  which  arms  and  chin-pieces  can  be  attached  (after 
Moriarty). 

saviE  and  sulphate  of  strychnin,  and  a  little  wine,  will  all  assist 
in  restoring  and  maintaining  good  health. 

Abscesses  which  appear  should  be  treated  by  incision,  evacua- 
tion of  their  contents,  drainage,  and  antiseptic  dressings.  Bits 
of  necrosed  bone  should  be  removed.  Union  in  fracture  of  the 
jaw  occurs  ordinarily  in  from  three  to  five  weeks.  The  apparatus 
is  to  be  worn  until  the  union  of  the  fracture  is  firm. 

Fracture  of  the  coronoid  and  articular  processes  is  to  be  treated 
bv  simple  immobilization  of  the  jaw. 

These  various  methods  of  immobilization  mentioned  may  fail 
in  some  unusual  fractures;  if  so,  suturing  of  the  fracture  through 
the  bone  with  silver  wire  or  other  material  should  be  undertaken. 


CHAPTER  III 
FRACTURES  OF  THE  VERTEBRAE 

Anatomy. — The  forked  spine  of  the  axis  may  be  felt  beneath 
the  occiput  upon  deep  pressure.  The  spines  of  the  third,  fourth, 
and  fifth  cervical  vertebrae  recede  from  the  surface,  and  can  not 
be  felt  distinctly.  The  spines  of  the  sixth  and  seventh  vertebrae 
project  distinctly,  and  can  be  palpated.  At  the  bottom  of  the 
furrow  in  the  middle  line  of  the  back  are  felt  the  spines  of  the 
dorsal  and  lumbar  vertebrae.  The  spinous  processes  from  the 
seventh  cervical  to  the  third  sacral  are  rather  easily  palpated. 
The  spinal  cord  extends  from  the  lower  edge  of  the  foramen  mag- 
num to  the  lower  border  of  the  body  of  the  first  lumbar  vertebra. 
The  phrenic  nerve  leaves  the  spinal  canal  between  the  third  and 
fourth  cervical  vertebrae.  By  palpation  through  the  mouth  (see 
Figs.  71,  72)  the  bodies  of  the  vertebrae  may  be  felt  down  to 
about  the  upper  border  of  the  body  of  the  fifth  vertebra.  The 
cervical  enlargement  of  the  spinal  cord  is  more  marked  than  the 
lumbar.  It  commences  at  the  third  cer\acal  vertebra  and  ends 
at  the  second  dorsal  vertebra.  The  lumbar  enlargement  com- 
mences at  the  level  of  the  ninth  dorsal  vertebra  and  reaches  to  the 
twelfth  dorsal  vertebra.  The  spinal  cord  is  well  protected  from 
injury  (see  Fig.  73). 

The  vertebrae  commonly  fractured  are  the  fourth,  fifth,  and 
sixth  cervical,  the  "twelfth  dorsal,  and  the  first  lumbar.  The  in- 
jury to  the  vertebrae  is  caused  in  one  of  three  ways :  by  a  direct 
blow,  fracturing  the  arches ;  by  a  fall  upon  either  the  head  or  the 
buttocks,  crushing  the  bodies  of  the  vertebrae;  or  by  forced 
flexion  or  extension  of  the  spine,  causing  a  dislocation  with  or 
without  fracture  of  the  bodies  and  articular  processes.  More 
than  one-half  of  the  fractures  of  the  cervical  vertebrae  are  frac- 
tures of  the  spinous  processes.  More  than  two-thirds  of  the  cases 
of  fracture  of  the  dorsolumbar  vertebrae  are  fractures  of  the  bodies 

72 


ANATOMY 


73 


of  those  vertebrae.     A  dislocation  without  fracture  may  occur  in 
the  cer^'ical  region ;  it  is  rare  in  other  regions  of  the  spine. 


pig_  71.— Palpating  the  bodies  of  the  first  and  second  cervical  vertebra;  through  the  nioulh. 


Fig.  72.— Palpating  the  bodies  of  the  cervical  vertebrae  through  the  mouth.     Finger  reaches 
about  to  the  fourth  cervical  vertebra. 


It  is  important  in  locaHzing  spinal-cord  lesions  to  know  the 
point  at  which  each  nerve  arises  from  the  spinal  cord,  because  the 
point  of  origin  does  not  correspond  with  that  at  which  the  nen.-e 


74 


FRACTURES  OF  THE  VERTEBRA 


emerges  from  the  spinal  canal  (see  Fig.  74).  The  point  of  origin 
is  higher  than  the  point  of  exit.  Many  of  the  nerves  pass  obliquely 
from  the  cord,  lying  still  within  the  vertebral  canal  after  leaving 
the  cord  (see  Fig.  75).  These  nerves  within  the  canal  are  liable 
to  pressure  from  the  vertebral  fracture.  For  example,  a  fracture 
of  the  eleventh  dorsal  vertebra  would  injure  not  only  the  cord 


Fig-  73 


-The  cord  and  its  membranes  in  relation  to  a  vertebra  (diagram) :  a,  Extradural 
space;  d,  dura  ;  c,  subarachnoid  space  ;  d,  spinal  cord. 


Fig.  74.— Frontal  section  of  fourth, 
fifth,  and  sixth  cervical  vertebras  and 
cord,  showing  the  origins  of  spinal 
nerve-roots  (after  Riidinger). 


F'g'-  75- — Frontal  section  of  third,  fourth,  and  fifth 
dorsal  vertebrae,  showing  oblique  course  of  nerve  bun- 
dles running  downward  (after  Riidinger). 


at  this  level,  but  in  addition  might  injure  the  last  dorsal  and  upper 
lumbar  nerves.  The  lower  the  spinal  nerves  arise,  the  longer  is 
their  intraspinal  course.  The  points  of  origin  of  the  spinal  nerves 
from  the  cord  with  reference  to  the  spines  of  the  vertebrae  are  as 
follows  (see  Fig.  76) :  The  eight  cervical  nerves  arise  from  the 
cord  between  the  occiput  and  the  sixth  cervical  spine.  The  upper 
six  thoracic  nerves  arise  from  the  cord  between  the  sixth  cervical 


EXAMINATION  75 

sj)iiK'  and  llic  fourth  dorsal  spine.  TIk-  lower  six  thoracic  nerves 
arise  frtmi  the  cord  between  the  fonrth  and  tenth  df)rsal  spines. 
The  five  lumbar  nerves  arise  from  the  cord  opposite  to  the  eleventh 
and  twelfth  dorsal  spines.  The  five  sacral  nerves  arise  from  the 
cord  opposite  to  the  first  lumbar  spine.  Xo  hard-and-fast  rule 
at  present  is  applicable  to  the  enumeration  of  the  lesions  following 
fractures  and  dislocations  of  definite  vertebrae.  From  the  com- 
bined experience  of  such  clinicians  as  Gowers,  Thorburn,  Kocher, 
Putnam,  Dennis,  Walton,  Bullard,  Thomas,  and  others  the  follow- 
ing table  is  constructed,  and  is  valuable  for  practical  use  : 


TABLE  STATING  LESIONS  FOLLOWING  INJURY  TO  DEFINITE 

VERTEBR.-E. 


Spinal 
Seg.ments. 


Muscles  Involved. 


Vertebr.*; 
Dislocated. 


Cervical  : 

First,    second, 

third    .    .    .  [Death].  Skull  on  atlas,  atlas  on 

axis. 

Fourth     .    ,    .  Diaphragm.  Axis  on  third  cervical 

Fifth     ....  Biceps,  supinators,  deltoid.  Third  on  fourth. 

Sixth    ....  Pronators,  triceps.  Fourth  on  fifth. 

Seventh   .    .    .  Extensors,  flexors  of  wrist.  Fifth  on  sixth. 
Eighth  and  first 

dorsal  .    .    .  Intrinsic  muscles  of  hand.  Sixth  on  seventh. 


Reflexes  In- 
volved. 


Pupil  is  small 
and  reaction 
sluggish. 


Dorsal : 

Second     to 


twelfth     . 

.  Intercostal  and  abdominal                       ...                       Epigastric,  ab 

muscles  (trunk).                                                                 dominal. 

umbar  : 
Second    .    . 

.  Cremaster.                                  Eleventh     on     twelfth    Cremasteric. 

dorsal. 

, 

Adductors. 

Third        1 
Fourth      :    . 
Fifth 

Outward  rotators.                     „      .^,        ^      .       ,           Gluteal. 

,    ,.   ,     „              Twelfth  on  hrst  lumbar.     ^.         .     , 
Extensors  of  thigh,  flexors                                                  Knee-jerk. 

of  knee. 


Sacral : 

First     ....  Extensors  of  foot. 


Second    .    .    .  Calf  muscles. 
Third,  fourth, 

fifth      ,    .    .  Perineal  muscles. 


First  on  second  lumbar.  Plantar  and 
ankle  -  clo- 
nus. 


76 


FRACTURES  OF  THE  VERTEBRA 


Examination  of  an  Injury  to  the  Spine. — Four  questions 
are  to  be  answered :  What  was  the  nature  of  the  accident  ?  What 
does  palpation  of  the  spine  reveal  as  to  the  nature  of  the  lesion? 
What  is  the  level  of  the  lesion?  Is  the  lesion  partial  or  com- 
plete ? 

General  Symptoms  Common  to  Fractures  of  the  Vertebrae. 
— Signs  of  shock  will  be  present.  At  the  seat  of  the  bony  lesion 
will  be  found  pain,  tenderness,  abnormal  mobility  and  sometimes 


y..S  cervical 
nerves- 


v_Jl-' 


6  dorsal 


, Lohier  6 

dorsal  rierves- 


5  sacral  n- 


Fig.  76. — Diagram  of  spinal  origin  of  nerves,  according  to  the  level  of  the  spinous  processes. 


crepitus  and  deformity.  The  deformity  will  ordinarily  be  a  back- 
ward bending,  or  kyphosis,  of  the  spinal  column  at  the  seat  of  frac- 
ture, unless  there  exists  a  unilateral  dislocation,  when  the  deform- 
ity will  be  irregular  in  appearance.  The  chief  symptoms  depend 
upon  the  injury  done  to  the  spinal  cord.  In  general  it  may  be 
stated  that  motor  and  sensory  paralysis,  either  partial  or  com- 
plete, will  be  found  up  to  the  level  of  the  lesion.  The  reflexes  are 
ordinarily  below  the  lesion,  wanting  at  first  and  increased  later.    If 


SYMPTOMS  77 

a  complete  lesion  is  present  the  reflexes  will  be  entirely  wanting. 
Retention,  and  later  incontinence,  of  urine  and  feces  will  exist. 
Cystitis  of  the  urinary  bladder  will  develop  at  an  early  date.  Bed- 
sores and  great  sloughing  areas  of  skin  upon  dependent  parts  will 
be  discovered  early.     Priapism  occurs. 

Symptoms  of  Fracture  of  the  Different  Regions  of  the 
Spine,  the  Cord  Being  Involved. — Injuries  to  the  Last  Dorsal 
and  Lnmhar  Vcrtcbrcc  (see  Figs.  77,  78,  79). — The  spinal  cord  ends 
opposite  the  lower  border  of  the  first  lumbar  vertebra.  Any 
pressure  at  this  point  or  below  will  involve  the  cauda  equina  in 


Fig.  77. — Fracture  of  the  twelfth  dorsal  vertebra.     Anesthesia  to  the  height  of  the  anterior 
superior  spinous  processes  in  front.     Second  lumbar  nerve  involved. 


whole  or  in  part  (see  Figs.  80,  81).  Local  evidences  of  the  bony 
lesions  may  be  present.  The  paralysis  of  the  legs  may  be  partial 
or  complete.  The  anesthesia  of  the  lower  limbs  is  partial  rather 
than  complete  and  up  to  the  level  of  the  bony  lesion.  Retention 
or  incontinence  of  urine  and  feces  exists.  The  paralyzed  muscles 
rapidly  become  wasted.  Constant  pain  and  hyperesthesia  may 
be  present  both  above  and  below  the  lesion.  The  patellar  and 
plantar  reflexes  are  usually  lost. 

The  prognosis  is  not  altogether  unfa^'orable  to  recover\\  Par- 
tial recover}-  is  possible.  Later,  muscular  contractures  will  exist 
in  the  lower  limbs,  which  impede  walking.     If  at  the  end  of  six 


78 


FRACTURES  OF  THE  VERTEBRAE 


Fig.  78.  Fig.  79. 

Figs.  78,  79. — Fracture  of  the  twelfth  dorsal  vertebra  without  involvement  of 
bar  nerve-roots,  the  ilioinguinal,  iliohypogastric,  and  external  cutaneous  nerv 
involved. 


the  first  lum- 
es  not  being 


Fig.  81. 

Figs.  80,  St.— Injury  to  the  cauda  equina,  which  has  involved  the  third  sacral  nerves.     Frac- 
ture of  the  first  lumbar  vertebra  or  the  second  lumbar  vertebra. 


SYMPTOMS 


79 


weeks  e\'i(leiices  of  l)e,i;innin,L,^  recovery  da  not  appear,  or  if  recover)- 
once  begun  has  ceased,  it  will  be  wise  to  operate  ui)on  injuries  to 
the  Cauda  equina. 

Injuries  to  the  Dorsal   Vertebrcc   (second  to  the  eleventh)    (see 


Fig.  82. — Sixth  dorsal  vertebra  fractured.     Anesthesia  at  the  level  of  two  inches  above  the 
umbilicus.     The  eighth  or  ninth  dorsal  nerve  involved. 


Fig.  83. — Lesion  of  spine  between  fifth 
and  sixth  cervical  vertebrse.  Note  position 
of  arms,  due  to  paralysis  of  subscapularis. 
Biceps  brachialis  anticus,  supinator  longus 
and  deltoid  muscles  intact.  Elbow  flexed, 
shoulders  abducted  and  rotated  outward 
(afterThorburn). 


Fig.  S4. — Luxation  of  sixth  and  seventh 
cervical  vertebree  ;  typical  attitude;  center  for 
subscapularis  not  involved.  Contrast  figures 
83  and  S4  (after  Kocher). 


Fig.  82). — The  simple  distribution  of  the  spinal  dorsal  nerves 
below  the  first  makes  the  interpretation  of  injuries  to  this  region 
much  easier  than  similar  injuries  to  the  cervical  or  lumbar  regions. 
The  arms  escape  paralysis.  The  motor  and  sensory  paralysis 
extends  ordinarily  to  the  height  of  the  bony  lesion.      In  a  few  cases 


8o 


FRACTURES  OF  THE  VERTEBRA 


in  which  the  nerve-trunks  within  the  canal  are  not  imphcated  the 
level  of  the  paralysis  wull  be  lower  than  the  lesion.  The  patellar 
reflexes  are  at  first  generally  lost  in  the  severer  types  of  fracture. 
If  the  patient  recovers,  there  will  be  spastic  paralysis  if  the  injury 
is  above  the  lumbar  enlargement.  If  the  lumbar  enlargement  is 
involved,  there  may  be  great  pain  in  the  legs. 

Injuries  to  the  Cervicodorsal  Region,  Opposite  the  Cervical  En- 
largement of  the  Spinal  Cord. — The  arms  escape  paralysis,  perhaps, 
at  first,  but  become  involved  after  several  days.  The  paralysis  is 
often  partial.  Respiration  is  diaphragmatic  only.  Pain  in  the 
arms  is  quite  constant.     If  the  sixth  vertebra  is  dislocated  upon 


Fig.  85. — Lesion  of  spine  between  sixth 
and  seventli  cervical  vertebras.  Position  in 
case  of  complete  transverse  destruction  of 
the  cord  just  below  nuclei  for  subscapularis  ; 
areas  of  anesthesia  shown  {after  Thor- 
burn). 


Fig-.  86. — Atlas,  axis,  and  third  cervical 
vertebra  from  the  front.  Case  :  man,  thirty- 
eight  years  of  age;  fell  from  a  cart.  Frac- 
ture of  odontoid  process.  Slight  hemor- 
rhage into  the  medulla.  Death  after  forty- 
eight  hours  (Cabot). 


the  seventh,  the  intrinsic  muscles  of  the  hand  will  be  paralyzed. 
If  the  fifth  vertebra  is  dislocated  upon  the  sixth,  there  wdll  appear 
a  characteristic  position  of  the  upper  extremities  (see  Fig.  83) : 
abduction  of  the  arms,  flexion  of  the  forearms,  with  rotation  out- 
ward of  the  whole  extremity.  If  the  injury  is  above  the  sixth 
cer^dcal  vertebra,  there  will  be  anesthesia  of  the  entire  limb  ex- 
cepting the  shoulder.  The  attitude  after  lesions  between  the  sixth 
and  seventh  cervical  vertebrae  is  shown  in  figure  84.  The  charac- 
teristic attitude  in  lesions  between  the  sixth  and  seventh  cervical 
vertebrae  is  also  shown  in  figure  84. 

Injuries  to  the  Midcervical  Region. — A  lesion  of  the  third  cervi- 


PROGNOSIS  AND  TREATMENT  8  I 

cal  vertfljia  will  iiuolvc  the  phrenic  nerve.  The  diaphragm  will  be 
paralyzed.      Death  will  occur  \vithin  a  few-  hours. 

Injiincs  to  flic  I-'iist  Two  Cervical  Vcricbnc  (see  Figs.  86,  87). — If 
the  displacement  is  slight,  life  may  be  spared  until  sudden  dis- 
placement occurs  or  a  secondary  myelitis  causes  death.  Cases 
of  recovery  are  recorded.  Death  usually  occurs  instantly.  Per- 
haps one  person  in  fifty  thus  injured  recovers  (Gow-ers). 

Prognosis. — The  prognosis  depends  upon  the  amount  of  injury 
to  the  spinal  cord.  The  prognosis  is  less  grave  than  it  was  thought 
to  be  a  few  years  ago.  There  is  a  probability  of  saving  a  certain 
proportion  of  cases.    In  general,  the  nearer  the  fracture  approaches 


Fig.  87. — Fracture  of  the  atlas  and  axis.  Man,  sevent3--four  years  of  age;  fall;  imme- 
diately left  arm  paralyzed.  No  loss  of  consciousness,  speech  thick.  Neck  movements  nor- 
mal. Twenty-four  hours  after  the  accident,  suddenly  difficult  breathing  appeared  and  death 
followed  (Brooks). 


the  medulla  oblongata  and  the  foramen  magnum,  the  more  serious 
does  the  outlook  become.  Patients  with  fracture  in  the  dorsal  and 
lumbar  regions  die  in  the  course  of  months  from  cystitis,  pyelitis, 
and  exhaustion.  Patients  with  fractures  in  the  upper  dorsal  and 
low^er  cervical  regions  die  in  a  few  days  or  weeks  from  hypostatic 
pneumonia.  Patients  with  fractures  high  up  in  the  cervical 
region  die  instantly  or  in  a  few  hours  from  shock  and  direct  pres- 
sure upon  the  medulla  oblongata. 

Treatment. — The  object  of  treatment  is  to  relieve  the  cord 
from  pressure  and  to  immobilize  the  fracture.     The  cord  will  be 
uninjured,  slightly  injured,  or  injured  seriously.      If  the  cord  is 
6 


82 


FRACTURES  OF  THE  VERTEBRA 


uninjured,  the  bony  parts  may  be  left  untouched  or  they  may  be 
replaced  by  manipulation  or  operation.  If  the  cord  is  injured, 
the  advisability  of  operative  interference  will  depend  upon  whether 
the  lesion  of  the  cord  is  transverse  and  complete,  or  whether  it  is 
partial.      If  there  are  evidences  of  a  transverse  lesion,  operation  is 

unavailing  and  obviously  illogi- 
cal, for  the  cord  can  not  be  re- 
paired. It  is  necessary,  there- 
fore, to  distinguish  between  the 
signs  of  a  transverse  lesion  and 
those  of  a  partial  lesion.  In  a 
complete  transverse  lesion  the 
history  of  the  onset  of  the  symp- 
toms is  a  sudden  one,  the  symp- 
toms appear  immediately  fol- 
lowing the  fracturing  trauma; 
whereas,  if  a  partial  injury  is 
present,  an  interval  will  have 
elapsed  before  the  symptoms  de- 
velop; the  appearance  of  symp- 
toms is  gradual  rather  than  sud- 
den. In  a  complete  transverse 
lesion  the  motor  paralysis  is 
found  to  be  complete,  and  the 
paralyzed  muscles  are  flaccid; 
whereas  if  the  lesion  is  a  partial 
one,  the  motor  paralysis  is  limit- 
ed, some  muscles  of  the  limbs  are 
paralyzed,  others  are  not,  and 
there  is  often  noticed  muscular 
spasm  in  the  affected  limbs.  In 
a  complete  transverse  lesion  sen- 
sation is  entirely  gone ;  whereas  in  a  partial  lesion  some  sensation 
is  present.  The  knee-jerks  are  variable;  in  the  complete  trans- 
verse lesion  they  are  absent.  In  the  partial  lesion  the  knee-jerks 
are  apt  to  be  absent  at  first,  and  they  may  return  later.  In  the 
transverse  lesion  the  paralysis  of  the  bladder  and  rectum  is  com- 
plete ;  whereas  in  the  partial  lesion  paralysis  of  these  organs  is  not 


Fig.  88. — Fracture  of  the  cervical 
spine  ;  cord  compressed  by  bone  and 
blood.  Hemorrhage  into  the  cord  at  the 
seat  of  the  lesion  and  below  the  lesion 
(Warren  Museum).     (Drawn  by  Byrnes.) 


TREATMENT 


83 


Fig.  89. — Spine  sawed  in  sagittal  sec- 
tion, showing  fracture  through  the  inter- 
vertebral disc  between  the  sixth  and 
seventh  cervical  vertebrae,  with  disloca- 
tion forward  of  the  upper  fragment.  Par- 
tial crush  ot  the  cord  (Thomas). 


Fig.  90.— Spine  sawed  as  before.  Fracture 
of  the  spinous  processes  of  the  seventh  cervi- 
cal and  first  and  second  dorsal  vertebrae. 
Fracture  of  the  bodies  of  the  fifth,  sixth,  and 
seventh  cervical  vertebrae  with  displacement 
backward  o{  the  upper  fragment.  Total  crush 
of  the  cord.  The  section  passes  a  little  to  one 
side  of  the  cord,  which  is  seen  in  place,  and 
the  staining  of  the  cord  by  hemorrhage  into  its 
substance  shows  plainly  through  the  mem- 
branes, even  in  the  photograph.  The  spinous 
processes  of  the  second  and  third  dorsal  verte- 
brae were  found  fractured  at  the  operation,  and 
were  removed  (Thomas). 


Fig.  gt. 


Figs  91  and  92.-Spine  sawed  as  before.  Fracture  of  spines  of  fiftli  cervical  and  fourtli, 
fifth  and  sixth  dorsal  vertebra.  Fracture  of  body  of  sixth  dorsal  vertebra.  Displacement 
forward  of  upper  fraRnient.  Total  crush  of  the  cord,  the  softened  substance  of  which  has 
been  removed  by  the  saw,  leaving  only  the  empty  and  blood-stained  meninges  at  this  point. 
Figure  91  shows  the  spine  as  sawed  ;  figure  92,  the  same  hyperextended,  showing  the  oblitera- 
tion of  the  narrowing  of  the  spinal  canal  (Thomas). 


TREATMEXT 


85 


always  present.  Priapism,  sweating,  and  involuntary  muscular 
twitchings  are  seen  more  commonly  in  case  of  injury  to  the  spine 
associated  with  complete  lesions  of  the  cord  than  in  cases  with 
partial  lesions  of  the  cord.     In  partial  lesions  variations  from  the 


Figs.  93  and  94.— The  two  halves  of  the  spine  sawed  in  sagittal  section.  Fracture  of  the 
seventh  cervical  vertebra,  with  dislocation  forward  of  the  upper  fragment.  Fracture  of  the 
arch  of  the  sixth  and  of  the  spine  of  the  seventh  vertebrae.  Total  crush  of  the  cord.  The 
discoloration  of  the  cord  from  blood  shows  plainly  in  the  plate  (Thomas). 


definite  types  of  symptoms  are  seen.  The  symptoms  are  more  or 
less  irregular.  In  total  lesions  of  the  cord  operation  can  do  no 
good.  The  cases  of  pressure  from  fragments  of  bone — that  is, 
those  occurring  for  the  most  part  in  the  cer\-ical  region,  in  which 
the  laminae   of  the  vertebrae  are  fractured — demand  operation. 


86 


FRACTURES  OF  THE  VERTEBRA 


All  other  cases  of  bony  pressure  are  those  due  to  dislocation  of 
vertebrae  which  are  remediable  either  by  operation  or  manipula- 
tion. In  these  cases  the  prognosis  depends  upon  the  damage 
done  the  cord. 

It  is  the  result  of  experience  that  in  cases  of  injury  to  the  spine 
severe  enough  to  do  damage  to  the  cord  usualh^  irreparable  injury 
has  been  done  by  either  a  distinct  crush  of  the  cord  or  hemorrhage 
into  the  cord.  Hemorrhage  into  the  cord  takes  place  often  ex- 
tensively and  some  distance  from  the  seat  of  the  chief  lesion,  so 


Fig.  95. — Case:  Man,  fracture  of  spine;  transverse  section  of  spinal  cord  above  tlie  lesion. 
Hemorrhage  into  posterior  horn  (Taylor).     (Drawn  by  Byrnes.) 


that  even  if  the  seat  of  the  crush  of  the  cord  were  reached  by 
operation,  damaging  lesions  would  still  remain  unrelieved. 

It  is  also  a  result  of  experience  that  removal  by  operation  of  the 
laminae  and  spines  of  the  vertebrae  in  the  suspected  region  of  frac- 
ture very  rarely — almost  never — reveals  any  remediable  condi- 
tion or  affords  any  evidence  of  the  exact  seat  of  the  lesions  or  their 
extent.  The  reason  for  these  facts  is  that  the  dura  at  the  seat  of 
a  crush  of  the  cord,  whether  partial  or  complete,  remains  intact 
and  untorn,  and  that  extradural  hemorrhage  is  unusual.  The 
surgeon,  therefore,  after  removal  of  the  laminae,  is  as  much  in 
doubt  as  he  was  before.  Operation,  therefore,  in  complete  lesions 
holds  out  no  hope  of  benefit.     It  is  said  that  the  chances  of  the 


TREATMENT 


87 


s^•nlptoms  being  clue  to  pressure  by  extradural  blood-clot  or  bone 
justify  operative  interference  in  these  apparently  hopeless  cases. 
This  is  true  in  those  cases  in  which  the  lesion  of  the  cord  is  partial, 
but  never  when  the  lesion  is  completely  transverse. 

Operaiivc  iiifcrferciicc,  then,  may  be  sii))i))i<irizcd  somewhat  as  fol- 
lows : 

In  partial  lesions  operation  ma}'  be  demanded;  in  fracture  of 
the  laminae  and  spines  operation  is  demanded;  in  all  lesions  of 
the  Cauda  equina  operation  is  demanded;  in  almost  all  complete 
lesions  operation  is  contraindicated. 

It  is  an  interesting  fact  clinically  and  pathologically  that  in 


Fig.  96. — Case:  Man,  fracture  of  spine  ;  transverse  section  of  spinal  cord  below  the   lesion 
(Taylor).     (Drawn  by  Byrnes.) 


cords  compressed  at  a  definite  level  with  destruction  of  the  cord, 
at  the  seat  of  compression  there  is  often  found  a  hematomyelia 
(hemorrhage  into  the  substance  of  the  cord)  several  vertebrae 
above  and  below  the  fracture,  thus  showing  how  extensive  is  the 
acting  force. 

A  study  of  the  drawings  made  from  actual  sections  of  the  spinal 
cords  of  cases  of  fracture  of  the  spine  will  indicate  the  different 
lesions  already  mentioned. 

Figure  88  is  from  a  fracture  of  the  cervical  vertebrae,  showing 
destruction  of  the  cord  at  the  seat  of  the  lesion,  with  localized 
pressure  from  bone  and  blood.     Low  down  is  seen  an  extensive 


88 


FRACTURES    OF    THE)    VERTEBRAE 


extradural  hemorrhage  and  a  hematomyelia  some  distance  from 
the  original  trauma. 


Fig.  97.— Case:  Man,  fracture  of  spine  ;  transverse  section  of  spinal  cord  at  the  seat  of 
lesion  (Taylor).     (Drawn  by  Byrnes.) 


Fig.  gS.— Case:  Fracture  of  the  spine;   transverse  section  of  spinal  cord  several  seganents 
from  the  lesion  ;  hemorrhage  into  the  white  matter  (Taylor).     (Drawn  by  Byrnes.) 


Figure  95  is  from  a  dislocation  and  fracture  of  the  fifth  upon  the 
sixth  cervical  vertebra.     There  was  complete  paralysis  below  the 


TRI'ATMENT 


89 


It'sion.  Trcpliiniiii;-  was  done.  The  patient  lived  without  im- 
provement seventeen  days.  This  section  of  the  cord  is  taken  a 
little  above  the  lesion  and  shows  clearly  a  hematomyelia  of  the 
right  posterior  cornu. 

Figure  96  is  taken  from  a  section  of  the  cord  of  the  preceding 
case  a  little  below  the  lesion,  showing  complete  destruction  of  the 
grav  matter  of  the  cord  ;  the  dura  remained  intact. 


Fig.  99. — Fracture  of  lumbar  vertebrEe  (Warren 
Museum). 


Fig.  100. — Partial  fracture  of  twelfth 
dorsal  and  fracture  of  first  lumbar 
vertebrae.  Fall  of  twenty  feet  on  nates. 
Paraplegia  and  sphincter  paralysis. 
Death  nine  months  after  accident.  Died 
of  phthisis.  Type  of  compression  frac- 
ture (Warren  Museum,  specimen  941). 


Figure  97  is  also  taken  from  a  section  of  the  cord  of  the  preced- 
ing case,  but  at  the  seat  of  the  lesion,  showing  a  destruction  of  the 
gray  and  white  matter  of  the  cord  anteriorly  next  to  the  bodies  of 
the  vertebrae.  The  dura  remained  intact,  there  being  to  the  oper- 
ating surgeon  no  evidence  posteriorly  of  any  disturbance  having 
occurred  anteriorly. 

Figure  98  is  a  section  of  the  spinal  cord  of  a  woman  who  fell 
from  a  trapeze  to  the  net,  and  fractured  and  dislocated  the  sixth 


90 


FRACTURES  OF  THE  VERTEBRA 


cervical  vertebra.  Operation  was  done.  She  lived  three  days. 
A  little  distance  (two  segments)  from  the  seat  of  the  lesion,  where 
the  cord  was  crushed  anteriorly,  was  found  a  hematomyelia  of  the 
white  matter  posteriorly.     The  dura  was  intact. 

These  specimens,  which  illustrate  the  common  lesions  of  the 
spinal  cord  following  fractures  and  dislocations  of  the  vertebrae, 
demonstrate  the  utter  futility  of  operative  interference  in  cases  of 
crush  of  the  cord  with  signs  of  a  complete  transverse  lesion. 


rlN. 


Fig.  loi.— Old  fracture  of  twelfth  dorsal  ver- 
tebra, from  fall  of  thirteen  feet ;  canal  nar- 
rowed. Total  paralysis  of  motion  and  sensa- 
tion below  injury.  Died  two  years  after  acci- 
dent (Warren  Museum,  specimen  4629). 


Fig.  102  — Fracture  of  twelfth  dor- 
sal vertebra.  Laceration  of  interver- 
tebral disc  above  twelfth  vertebra ; 
crushed  by  fall  of  ceiling.  Paralyzed 
from  below  navel.  Paralysis  of  blad- 
der and  rectum.  Died  nine  and  a  half 
weeks  after  the  accident. 


The  Immediate  Rectification  of  the  Deformity  and  Immobilization 
by  the  Plaster-of- Paris  Jacket. — With  our  present  knowledge  of 
the  pathology  of  these  fractures,  and  excepting  cases  of  fracture  of 
the  vertebral  arch  alone  and  pressure  upon  the  cauda  equina  and  par- 
tial lesions  of  the  cord,  there  can  be  no  doubt  that  the  best  treat- 
ment for  fracture  of  the  vertebrae  is  by  means  of  expectant 
methods.  The  methods  are  as  follow^s:  Immobilization  of  the 
part  by  a  plaster-of -Paris  jacket  applied  to  the  trunk,  if  there  is 
no  deformity.     If  there  is  deformity,  correction  of  it  and  immo- 


TREATMENT 


91 


bilization  of  the  spine  in  the  corrected  p(Jsition.  The  correction 
of  the  deformity  nuist  be  immediate  to  avoid  irremediable  soften- 
ing of  the  cord  from  pressure ;  and  this  may  occur  even  within 
forty-eight  hours. 

I^Iethod  of  Applying  the  Plaster-of-Paris  Jacket.— This  differs 

in  no  respect  from  the  usual 
methods  of  application, 
with  the  exception  that  the 
patient  should  be  protected 
from  any  unusual  or  sudden 
jar  or  movement.  The 
trunk  having  been  properly 
protected  by  a  tightly  fit- 
ting shirt,  the  patient  is 
carefully  placed  prone  in  a 
hammock.  The  patient 
mav   be   placed  upon  two 


Fig.  103.— Fracture  of  seventh  dorsal  vertebra, 
with  great  displacement  of  fragments,  from  a  fall  of 
thirty  feet.  Paraplegia,  loss  of  sensation  from 
nipple  down.  Sensation  later  recovered  down  to 
navel.  Died  two  months  after  accident  (Warren 
Museum,  specimen  6229). 


Fig.  104.— Dislocation  forward  of 
sixth  cervical  vertebra,  from  fall  on 
head.  Total  paralysis  below  nipples. 
Temperature  rose  to  1 10'^  F.  Died  eigh- 
teen hours  after  accident.  Illustrates 
displacement  of  spinous  processes 
(Warren  Museum,  specimen  4904). 


kitchen  tables,  which  are  gradually  pulled  apart,  allowing  the 
trunk  to  be  unsupported  between  the  tables  until  the  desired  ex- 
tension is  obtained.  If  the  tables  are  used,  great  care  must  be 
exercised  that  proper  assistants  secure  the  shoulders  and  hips  of 
the  patient  during  the  procedure.  Gentle,  firm  pressure  is  made 
upon  the  projecting  vertebral  spines  until  reduction  is  complete. 
The  jacket,  reinforced  posteriorly  by  extra  layers  of  bandage,  is 
then  applied.     Death  may  occur  instantly  during  this  procedure. 


92 


FRACTURES  OF  THE  VERTEBRA 


but  if  gentle  measures  are  used,  the  likelihood  of  such  a  catas- 
trophe will  be  modified.  An  anesthetic  given  to  primary  anes- 
thesia is  often  of  service.  A  sufficient  number  of  assistants  should 
be  at  hand — there  should  be  at  least  four. 

It  is,  of  course,  impossible  to  say  what  cases  will  be  saved  by  this 
means,  but  it  has  been  proved  to  be  a  life-saving  measure  in  a  few 
cases.  The  patient  will  be  more  comfortable  and  more  easily  man- 
aged after  such  a  procedure.     The  hopelessness  of  the  results  of 


Fig.  105.— Fracture  and  subluxation  ;  cervical  vertebras  united  (J.  Mason  Warren  collec- 
tion, Warren  Museum)  (Walton). 


fractured  spine  justifies  the  surgeon  in  undertaking  almost  any 
risk. 

Cystitis.— iMe  may  be  prolonged,  if  not  saved,  by  the  proper 
treatment  of  this  distressing  affection,  which  is  always  associated 
with  fracture  of  the  spine.  In  a  number  of  these  cases  death  is 
due  to  a  pyelitis  and  nephritis  following  a  cystitis.  These  com- 
plications may  be  avoided  for  a  definite  time  if  the  bladder  is  thor- 
oughly drained  by  urethral  catheter  or  by  perineal  drainage.  The 
bladder  may  be  kept  aseptic  by  douching  regularly  with  a  solution 


GUNSHOT   FRACTURES   OF    THE    VERTEBRA  93 

of  boric  acid  or  permanganate  of  potash  and  by  the  internal  use 
of  urotropin.  Great  care  should  be  exercised  in  the  avoidance 
of  bed-sores ;  it  is  easier  to  prevent  than  to  cure  them. 

SiDuwary  of  Treatment. — Fracture  of  the  arches  of  the  vertebrae, 
whether  open  or  closed,  should  be  subjected  to  operation.  Frac- 
ture and  compression  of  the  cauda  equina  after  six  weeks  of  waiting 
for  spontaneous  recovers-  should  be  treated  by  operation.  In 
partial  lesions  of  the  cord  operation  may  be  demanded.  All  other 
fractures  showing  a  complete  transverse  lesion  of  the  cord  should 
be  treated  expectantly. 

GUNSHOT  FRACTURES  OF   THE  VERTEBRAE 

These  open  fractures  arrange  themselves  into  three  groups  for 
practical  purposes. 

First  group.  Those  cases  in  which  the  viscera  of  the  thorax 
or  abdomen  are  simultaneously  injured. 

Second  group.  Those  cases  in  which  the  bullet  has  entered 
the  spinal  canal  and  has  injured  the  spinal  cord. 

Third  group.  Those  cases  in  which  the  spines  and  laminae  or 
the  arches  of  the  vertebrae  are  injured. 

Treatment. — In  all  cases  the  external  wound  should  be  care- 
fully cleansed  and  protected  by  an  antiseptic  dressing. 

The  degree  of  shock  should  be  obser^-ed.  Any  signs  of  a  lesion 
of  the  cord  should  be  recorded.  Evidence  of  damage  to  the  vis- 
cera within  the  chest  or  abdomen  should  be  sought  for. 

In  the  absence  of  great  shock  it  is  wise  for  the  surgeon,  under 
antiseptic  and  aseptic  conditions,  to  lay  open  the  wound,  to  thor- 
oughly disinfect  it  and  to  attempt  to  ascertain  the  condition  of  the 
cord  and  vertebrae.  If  the  symptoms  point  immediately  to  a  trans- 
verse lesion  of  the  cord  extensive  operation  is  contraindicated. 

The  character  of  the  damage  done  by  the  bullet  to  the  vertebrae 
and  spinal  cord  cannot  be  wholly  determined  except  by  operation. 
In  operating  there  is  always  the  possibility  of  diminishing  the 
chances  of  infection  through  the  bullet  wound  and  of  relieving 
pressure  upon  the  spinal  cord  from  blood  clot  and  fragments  of 
bone. 

A  crushed  cord  is  not  incompatible  with  life.  Such  a  patient 
may  live  for  several  months  or  even  for  several  years.  Operation 
may  prevent  death  from  sepsis,  even  if  a  crush  of  the  cord  exists. 


CHAPTER  IV 
FRACTURES  OF  THE  RIBS 

Anatomy. — Palpation  of  most  of  the  ribs  is  comparatively  easy. 
The  upper  seven  ribs  on  each  side  articulate  with  the  sternum. 
The  eighth,  ninth,  and  tenth  ribs  are  connected  by  the  costal  car- 
tilages anteriorly,  but  the  eleventh  and  twelfth  ribs  have  no  ante- 
rior attachment.  These  lowest  ribs  are,  therefore,  less  liable  to 
fracture.  The  first  two  ribs  are  somewhat  protected  by  the  clavi- 
cle from  direct  violence,  although  great  depression  of  the  shoulder 
may  bring  the  clavicle  to  bear  directly  upon  the  first  ribs,  and  this 
may  be  a  cause  of  fracture.  The  ribs  are  so  elastic  in  childhood 
that  fracture  then  is  extremely  rare.  Direct  violence  is  the  com- 
mon cause  of  fracture. 

Symptoms. — In  partial  fractures  there  may  be  no  symptom^s. 
Upon  forcible  expiration  (as  in  sneezing,  coughing,  laughing,  cry- 
ing, or  in  breathing  hard)  pain  may  be  felt  at  the  seat  of  fracture. 
So  definite  is  the  pain  that  the  patient  may  be  able  to  place  his 
finger  accurately  upon  the  seat  of  fracture. 

Crepitus  is  often  felt  by  the  patient  when  moving  or  making 
an  expulsive  effort.  Crepitus  is  elicited  for  the  examiner  by  firmly 
placing  the  palm  of  the  hand  flat  upon  the  chest  at  the  supposed 
seat  of  fracture  when  the  patient  coughs.  If  crepitus  is  present  at 
the  time  of  coughing,  a  slight  crunch  or  click  will  be  felt  and  some- 
times heard.  The  stethoscope  placed  near  the  supposed  fracture 
will  often  assist  in  detecting  the  crepitus.  The  ribs  should  be 
palpated  systematically,  and  the  chest  slightly  compressed  be- 
tween the  two  open  hands  anteroposteriorly  and  laterally  to  detect 
crepitus.  The  natural  inclination  of  the  ribs  should  be  borne  in 
mind  during  palpation.  Respiration  will  be  short  and  catchy, 
and  accompanied  by  a  characteristic  grunt. 

The  attitude  and  movements  of  the  patient  are  very  deliberate, 
guarded,  stift',  and  in  severe  cases  suggest  the  movements  of  a  child 

94 


COMPLICATIONS    OF    FRACTURE    OF    A    RIB 


95 


with  acute  caries  of  the  dorsal  spine.     There  may  be  a  shght 
cough. 

Complications  of  Fracture  of  a  Rib. — Injury  to  the  pleura 
and  lung  not  uncommonly  occurs.  Its  existence  is  manifested 
by  cough,  bloody  expectoration,  and  emphysema.  Emphysema 
may  extend  over  the  whole  chest  and  up  over  the  neck  and  face 
(see  Fig.  106),  and  even  over  most  of  the  body.  Emphysema 
unassociated  with  a  woimd  of  the  superficial  soft  parts  is  of  little 
importance.  Pneumothorax  may  be  present.  Injury  to  the 
heart  and  pericardium  and  hemorrhage  from  an  intercostal  artery 


Fig.  106. — Case  :  Emphysema  following  fracture  of  tlie  ribs  on  the  right  side.     Note  the  puffi- 
ness  of  the  face — the  eyes  almost  closed  (Warren). 


are  unusual.  A  dry  pleurisy,  disappearing  rapidly,  localized  at 
the  seat  of  fracture,  is  quite  commonly  detected  by  the  steth- 
oscope. The  relations  of  a  rib  to  the  pleura  and  intercostal  ves- 
sels are  important  in  this  connection  (see  Fig.  109). 

Treatment. — The  complications  must  be  attended  to  according 
to  medical  principles.  A  cough  mixture,  if  necessarv-,  containing 
morphin  is  a  great  help  during  the  first  week.  It  is  difficult  to 
reduce  a  fracture  of  a  rib  and  to  hold  it  reduced.  The  deformity 
and  loss  of  function  consequent  upon  the  union  of  a  fractured  rib 
in  malposition  is  fortunately  not  very  great  (see  Fig.  no).      How- 


96 


FRACTURES    OF   THE    RIBS 


Fig.   107. — Fracture  of  ribs.     Emphysema  general.     Adhesive-plaster  swathe    about  chest. 
Note  closure  of  right  eye  and  puffiness  of  face  and  hands  (Monks). 


m- 

* 

1 

0 

/    .   ^ 

^g^^TZ^^fcliit&at 

«» 

V       y'l     M 

^ 

« 

Fig.  108. — Same  case  as  figure  107.     Emphysemi  entirely  disappeared.     Contrast  the  two 
appearances  (Monks). 


TRICATMENT 


97 


ever,  Uk-  rc-licl"  of  llic  ])aliL'nt  upon  the  partial  immobilization  of 
the  fracture  is  great.  By  pressure  of  the  hand  the  ribs  may  be 
steadied  and  the  fragments  brought  into  excellent  apposition,  and 
by  a  pad  held  in  place  by  a  swathe  of  adhesive  plaster  this  apposi- 
tion can  be  maintained.  The  application  of  an  adhesive-plaster 
swathe  is  attended  with  much  comfort,  and  is  easily  accom- 
plished. The  swathe  should  be  broad  enough  to  cover  the  chest 
six  inches  on  either  side  of  the  fracture  of  the  rib,  and  long  enough 


Lung. ri^  -~ 


Rib. 


Artery  and  nerve. 
Pleura. 


Rib. 
Arterv. 


—    Rib. 


Fig-,  log. — Horizontal  section  of  cliest-wall.  The  relation  of  rib  and  intercostal  vessels  and 
nerve  to  pleura  and  lung  is  shown.  Fracture  of  rib  may  cause  serious  injury  (frozen  section, 
Professor  T.  Dwight). 


Fig.  no. — Fractured  rib,  united  with  displacement  (Warren  Museum). 


to  extend  three-fourths  of  the  way  around  the  body.  It  is  applied 
as  follows:  One  end  is  fixed  to  the  trunk  of  the  patient  at  the 
spine,  the  patient  standing  erect  with  the  hands  upon  the  top  of 
the  head  (see  Fig.  1 1 1).  The  surgeon,  taking  the  loose  end  of  the 
swathe  and  holding  it  taut,  walks  around  the  patient,  applying 
the  swathe  to  the  patient's  chest  while  the  patient  standing  turns 
as  if  on  a  pivot  toward  the  surgeon  if  possible  (see  Fig.  112).  It  is 
important  to  avoid  covering  the  constantly  moving  abdomen  by 
the  swathe.  A  swathe  made  of  several  long  strips  of  adhesive 
7 


i: 

w 

^■^ . 

1-  ^ 

■> 

jiM^" 

^^             ,;'^ 

[                                    '4 

_^ 

ij^^i 

^ 

^Ihs           '  "^ 

Fig.  III.  — Fracture  of  the  ribs.  Starting  the  application  of  the  adhe.sive-plaster  swathe 
to  encircle  the  trunk.  Fixation  of  initial  end  of  the  swathe  at  the  spine.  Notice  that  the 
swathe  is  held  taut  as  it  is  applied. 


Fig.  112. — Fracture  of  the  ribs.     Finishing  the  application  of  the  adhesive-plaster  swathe  to 

the  trunk. 


TREATMENT  99 

plaster,  each  strij)  bt-in.i^-  four  inches  wide,  imbricated  in  the  appH- 
cation,  will  often  prove  more  comfortable  than  a  single  swathe. 
The  comfort  attending  the  wearing  of  such  a  swathe  speaks  much 
for  its  efficacy. 

Operative  Treatment. — If  the  fracture  is  comminuted  or  if  there 
is  great  displacement  that  is  irreducible  by  pressure,  an  incision 
and  elevation  of  the  parts  and  immobilization  by  suture  are  to  be 
considered. 

After-treatment. — The  upright  position  will  give  the  most  com- 
fort. The  swathe  should  be  changed  at  least  once  each  week.  It 
will  require  about  three  weeks  for  the  union  to  become  firm.  A 
cotton  swathe  may  be  worn  during  the  third  and  fourth  weeks  in 
place  of  the  adhesive-plaster  swathe.  At  the  end  of  four  weeks 
all  swathes  may  be  removed.  Massage  to  the  seat  of  fracture  will, 
after  the  first  week,  hasten  healing  and  a  restoration  of  the  parts 
to  the  normal  position.  If  there  have  been  any  pleural  or  lung 
complications,  great  precaution  should  be  exercised  in  the  after- 
care. The  avoidance  of  exposure  to  cold  and  of  great  bodily 
exertion  for  a  period  of  two  months  or  more  following  recover}- 
from  the  complication  is  necessary. 

Other  injuries,  such  as  strains  of  the  shoulder  and  back,  are 
likely  to  appear  some  days  after  the  acute  symptoms  of  a  fracture 
of  the  rib  have  subsided.  It  is  ^Yell  to  examine  the  patient  wdth 
a  fractured  rib  for  associated  injuries.  These  associated  sprains 
often  cause  considerable  anxiety  to  the  patient  for  fear  that  more 
serious  trouble  than  a  broken  rib  exists.  In  patients  over  fifty 
years  old  "neuralgic  pain"  at  the  seat  of  fracture  will  sometimes 
persist  for  several  weeks  after  the  fracture  is  firmly  united.  This 
may  be  relieved  by  applications  of  moist  heat  to  the  affected 
part  and  by  count erirritation  of  a  more  vigorous  kind.  The  use  of 
tincture  of  iodin  and  blisters  is  often  a  great  help.  In  the  aged 
the  shock  of  the  injury  is  considerable.  In  feeble  persons  a 
pleurisy  or  pneumonia  may  prove  fatal. 

Treatment  directed  to  the  removal  of  the  emph3'sema  is  ordi- 
narily unnecessary.  The  emphysema  usually  disappears  in  a 
week  or  ten  days.  If  the  distention  of  the  subcutaneous  tissues 
is  extremely  painful  and  increases  very  rapidly  it  may  be  wise  to 
make  several  antiseptic  incisions  over  them,  allowing  the  air  to 
escape,  to  relieve  the  tension  of  the  skin. 


CHAPTER  V 

FRACTURES  OF  THE  STERNUM 

It  is  difficult  to  palpate  the  sternum  accurately.  The  episternal 
notch  is  felt  between  the  two  inner  ends  of  the  clavicles.  The 
junction  between  the  first  and  second  portions  of  the  sternum  is 
distinctly  felt  opposite  the  second  costal  cartilage  as  a  ridge.  The 
different  sites  of  fracture  are  shown  in  figure  113.     The  fracture 


Fig.  113. — Sites  ot  fracture  of  the  ster- 
num (after  specimens  5149,  978,  5151,  5150, 
976,  977,  Warren  Museum). 


Fig.  114. — Separation  of  manubrium 
and  gladiolus;  displacement  of  lower  por- 
tion forward  ;  side  view. 


that  is  usually  due  to  direct  violence  is  seated  in  the  upper  part  of 
the  second  portion  of  the  sternum,  near  the  junction  of  the  first 
and  second  portions.  The  upper  fragment  is  displaced  backward 
behind  the  upper  end  of  the  lower  fragment  (see  Fig.  114).  The 
displacement,  the  abnormal  mobility,  and  possibly  crepitus  after 


TREATMENT   OF   FRACTURE   OF   THE   STERNUM 


lOI 


each  respiratory  act  or  upon  couf^hiiig,  the  locaHzed  area  of  pain, 
all  increased  by  pressure,  help  to  make  the  diagnosis  certain. 

The  patient  stands  in  a  characteristic  fashion  with  body  bent 
forward.  It  is  almost  impossible  to  distinguish  a  dislocation  at 
the  junction  of  the  first  and  second  portions  of  the  sternum  from 
a  fracture  within  the  first  portion  of  the  sternum.  Careful  palpa- 
tion alone  and  consideration  for  the  age  of  the  patient  will  enable 
one  to  decide.  The  ossification  of  the  sternum  takes  place  irregu- 
larly. At  the  twenty-fifth  year  all  parts  are  usually  ossified. 
The  lesions  sometimes  associated  with  fracture  of  the  sternum — 
viz.,  fracture  of  the  ribs  and  injury  to  the  lungs  and  heart — are 


Fig.  115. — Position  in,  and  method  of  reduction  of,  fracture  of  the  sternum.     Notice  positions 
of  liands  of  surgeon  and  assistant. 


usually  SO  severe  that  the  patient  does  not  recover  from  them.  If 
no  complicating  lesions  are  present,  the  outlook  for  recovery  is 
favorable. 

Treatment  of  Fracture  of  the  Sternum. — Spontaneous  reduc- 
tion has  occurred  in  several  instances  upon  coughing  or  sneezing. 
If  the  patient  is  placed  upon  his  back  with  his  head  extended  over 
the  end  of  the  table  and  the  arms  are  then  raised  above  the  head 
and  rotated  outward  slowly  and  forcibly,  the  deformity  is  some- 
times reduced.  The  body  of  the  patient,  meanwhile,  is  steadied 
by  an  assistant.  Traction  and.countertraction  are  thus  made  upon 
the  two  fragments  (see  Fig.  115).  An  adhesive-plaster  swathe 
should  be  placed  about  the  chest  high  up,  and  held  firmly  in  posi- 


I02  FRACTURES   OF   THE   STERNUM 

tion  by  straps  across  the  shoulders.  Union  takes  place  in  from 
three  to  four  weeks.  The  fracture  is  not  solid  for  from  six  to  eight 
weeks.  After  resting  on  the  back  in  bed  for  three  weeks  the 
patient  may  be  allowed  to  be  up  occasionally  with  care  to  avoid 
violent  exertion.  For  the  greatest  precaution  a  Taylor  steel 
back-brace,  with  apron  and  head-support,  should  be  used  for  two 
months  after  the  patient  is  up  and  about.  This  brace  is  similar 
to  that  used  in  high  dorsal  caries  of  the  spine. 

Operative  Treatment. — Incision  and  elevation  of  the  depressed 
fragment  have  been  done  successfully,  and  are  to  be  considered 
in  difficult  cases  after  the  shock  of  the  original  injury  has  passed 
away.  Cyanosis  and  dyspnea  may  be  in  part  dependent  upon 
the  displacement  of  the  sternal  fragments.  Relief  from  these 
symptoms  is  often  immediate  upon  the  correction  of  deformity. 


CHAPTER  VI 
FRACTURES  OF  THE  PELVIS 

The  pelvic  bones  are  generally  considered  inaccessible  (see 
Fig.  ii6);  but  with  a  systematic  anatomical  examination,  espe- 
cially if  assisted  by  digital  examination  by  the  rectum  and  the 
vagina,  practically  all  parts  of  the  pelvic  bones  may  be  palpated. 
Movement  of  the  hip  will  often  determine  the  integrity  of  the 
acetabulum,  which  is,  of  course,  most  difficult  to  palpate  even 
posteriorly  by  the  rectum.  Fractures  of  the  pelvis  are  occa- 
sioned by  great  violence.  Fracture  occurs  most  often  in  falls 
from  a  height,  and  is  due  to  the  sudden  pressure  upon  the  pelvis 
through  the  thighs  and  hips  (see  Fig.  117)  or  through  the  spinal 
column  upon  the  sacrum  and  sacro-iliac  synchondroses.  Antero- 
posterior pressure  and  lateral  compression,  as  in  the  car-coupling 
accident,  are  common  causes  of  fracture.  From  a  clinical  stand- 
point these  fractures  fall  into  two  groups — fractures  of  the  indi- 
vidual bones  without  injury  to  viscera,  and  fractures  at  different 
points  in  the  pelvic  ring  usuallv  associated  with  visceral  lesions. 

Fractures  of  the  sacrum,  the  coccyx,  the  symphysis  pubis,  and 
the  ischium  are  extremely  rare. 

Examination. — The  examination  should  be  systematically 
made  in  order  to  cover  thoroughly  the  irregular  bones  of  the  pelvis. 
The  ilium  of  each  side  should  be  palpated  to  detect  a  fracture  of 
either  crest.  Then  the  two  ilia  should  be  crowded  genth-  but 
firmly  together  in  order  to  determine  crepitus  due  to  the  presence 
of  fracture  elsewhere.  Then  the  pubis  and  ischium  upon  the  two 
sides  are  to  be  palpated  externally  as  far  as  is  practicable.  Finally 
a  careful  rectal  and  vaginal  examination  should  be  made  of  the 
pelvic  bones.  The  patient  should  be  catheterized  to  assist  in 
determining  the  presence  of  an  injury  to  the  urinarv'  tract. 

Fracture  of  the  Ilium  (see  Fig.  iiS). — This  fracture  is  not  un- 
usual.    The  crest  of  the  ilium  is  commonlv  broken.     Pain,  swell- 


I04 


FRACTURES    OF    THE   PELVIS 


ing,  crepitus,  and  abnormal  mobility  may  be  present.  Localized 
tenderness  at  the  seat  of  fracture  may  be  the  only  sign  present. 
Crepitus,  absent  at  first,  may  be  ehcited  several  days  after  the 


Fig.  ii6.— Normal  pelvis.     Note  relations  of  pelvic  ring.  Fig.  117.— Fracture   of  acetab- 

ulum ;  force  transmitted  through 
femur  (Warren  Museum,  specimen 
1053). 


Fig.  118.— Fracture  of  crest  of  ilium  (Warren  Museum,  specimen  593S). 


injury.  There  is  comparatively  little  displacement.  Union 
occurs  in  from  three  and  a  half  to  four  weeks.  The  patient  or- 
dinarily requires  but  restraint  in  bed.     The  outlook  is  for  a  good 


TREATMENT   OF    I-RACTURES   OF   THE   PELVIS 


105 


recovery  unless  there  is  a  visceral  lesion.  Slight  deformity  may 
be  noticeable  upon  full  recovery  (see  Fig.  1 19). 

Fiacture  of  the  pubic  portion  of  the  ring  of  the  pelvis  is  the  com- 
monest fracture.  It  is  usually  associated  with  other  fractures  or 
separations  of  bony  surfaces  of  the  pelvis.  Injury  to  the  urethra 
is  not  uncommon  in  this  fracture  (see  Figs.  120,  121). 

Treatment. — A  snugly  fitting  swathe  encircling  the  pelvis 
should  be  applied  to  assist  in  immobilizing  the  fracture.  If  the 
fracture  is  of  the  ilium  alone,  the  swathe  should  be  applied  loosely 
enough  to  avoid  displacing  the  fragment  of  the  crest  inward,  thus 


Fig.  119.— Case  :  Fracture  of  the  crest  of  the  right  ilium  :  A,  Deformity  due  to  inward  displace- 
ment of  fractured  bone;  B.  Posterior  lateral  view  (Porter). 


causing  permanent  deformity  Csee  Fig.  119).  The  patient  should, 
in  all  cases,  except  simple  fractures  of  the  crest  of  the  ilium,  be 
placed  upon  a  properly  fitting  Bradford  frame.  Upon  this  frame, 
and  in  no  other  way,  can  the  patient  be  comfortably  nursed.  The 
bed-pan  can  be  adjusted  with  ease  and  without  disturbing  the 
fracture.  The  bed  can  be  most  readily  changed  and  the  patient 
kept  clean  and  comfortable.  If  it  is  probable  that  movements  of 
the  hip-joints  cause  motion  at  the  seat  of  the  fracture,  the  thighs 
should  be  fixed  so  as  to  immobilize  these  joints.  The  long  out- 
side wooden  splint  extending  from  the  axUla  to  below  the  heel 
and  attached  at  its  foot  end  to  a  slat  at  right  angles  to  the  long 


io6 


FRACTURES    OF   THE    PELVIS 


upright — a  T-splint — is  the  simplest  means  of  securing  this 
inimobihzation.  If  the  patient  is  on  a  Bradford  frame,  suffi- 
cient immobilization  is  easily  accomplished  by  encircling  the 
thighs  separately  or  together  and  the  frame  with  a  towel  swathe. 
Extension  of  the  limbs  by  weight  and  pulley  may  be  needed  in 


New  bone  at 
seat  of  separation. 


Fracture. 


Sacro-iliac 
synchondrosis. 


Fracture. 
Fig.  120.— Fracture  of  rami  of  pubes;  fracture  and  separation  at  sacro-iliac  synchondrosis; 
much  displacement;  bony  union  (Warren  Museum). 


Fig.  121.— Fractured  pelvis  :  on  the  right,  fracture  across  pubes  and  ischium  ;  on  the  left,  frac- 
ture involving  acetabulum  and  sacrosciatic  notch  (Warren  Museum,  specimen  3857). 


addition  in  certain  cases  to  secure  immobilization  of  the  fracture. 
Wiring  or  suture  of  the  fractured  bones  may  be  entertained  and 
practised.  Wiring  is  indicated  if  comminution  or  displacement 
of  fragments  is  great. 

Visceral  Lesions. — Associated  with  fractures  of  the  pelvis  there 


RUPTURE  OF  THE  URETHRA 


107 


may  be  lesions  of  important  viscera.  These  visceral  lesions  render 
fractures  of  the  pelvis  of  the  very  greatest  seriousness.  The 
trauma  causing  the  fracture  may  at  the  same  time  occasion  a  rup- 
ture of  the  kidney.  The  bladder,  urethra,  or  bowel  may  also  be 
ruptured.  The  shock  associated  with  a  fracture  of  the  pelvis  is 
great.  If  there  is  a  visceral  lesion,  the  primary  and  secondary 
shock  will  be  ver\-  great. 

Bladder. 


Sacrum.   — 


Rectum. 


Symphy- 

~    sis  pubis. 


Anus. 


Urethra. 


Fig.  122.— Median  section  of  male  pelvis.  Notice  close  relation  of  bladder  and  urethra  to 
the  symphysis  pubis.  Fracture  of  pubic  bone  may  injure  bladder  or  urethra  (frozen  section 
by  Professor  Thos.  Dwightj. 

Rupture  of  the  Urethra.— This  is  sometimes  associated  with 
fracture  of  the  pelvis  (see  Fig.  122).  It  may  be  due  to  the  original 
trauma,  as  a  fall  or  blow  on  the  perineum,  or  it  may  be  caused  by 
bonv  fragments  lacerating  the  urethra,  or  by  a  simple  separation 
of  the  symphysis  pubis.  Pain  at  the  seat  of  the  lesion,  pain  upon 
pressure  in  the  perineum,  retention  of  urine,  urethral  hemorrhage, 
swelling  in  the  perineum,  usually  exist.  Under  these  circum- 
stances perineal  section  is  indicated  in  order  to  drain  the  wounded 
area  and  the  bladder.     If  a  catheter  can  be  passed  to  the  bladder 


Io8  FRACTURES  OF  THE  PELVIS 

and  the  local  swelling  does  not  increase,  permanent  or  interrupted 
catheterization  is  indicated.  The  patient  should,  however,  be 
watched  carefully  for  the  signs  of  extravasation  of  urine.  If  at 
any  time  the  catheter  can  not  be  passed,  operation  should  be  done 
at  once,  as  in  the  first  instance. 

If  the  urethral  rupture  is  caused  from  above,  the  inferior  surface 
of  the  canal  may  be  intact.  If  so,  the  passage  of  the  catheter  (if 
difficult)  may  be  facilitated  by  depressing  the  instrument  slightly, 
hugging  the  inferior  wall  of  the  urethra. 

Rupture  of  the  Urinary  Bladder. — This  may  be  either  extra-  or 
intraperitoneal.  When  the  bladder  is  empty,  it  is  low  down  in 
the  pelvis  and  can  be  injured  only  by  a  fracture  of  the  pelvis.  The 
rupture  of  the  bladder  due  to  fracture  of  the  pelvis  is  usually  extra- 
peritoneal and  it  is  situated  on  its  anterior  surface. 

On  account  of  the  fracture  the  patient  can  not  walk.  Rupture 
of  the  bladder  itself  might  occasion  inability  to  walk,  at  least  any 
long  distance.  There  is  great  hypogastric  pain,  frequent  desire  to 
micturate  and  inabilit}^  to  pass  urine.  A  few  drops  of  bloody 
fluid  escape  from  the  meatus.  Dullness  may  be  present  in  the 
lower  abdomen  and  loins.  Soon  after  the  accident,  if  not  imme- 
diatelv,  there  is  great  prostration.  Evidences  of  shock  are  seen 
in  the  pallor  of  the  face,  the  anxious  expression,  the  feeble  pulse, 
the  cold,  clammy  skin,  and  feeble  voice.  The  abdomen  becomes 
distended,  the  temperature  rises,  and  delirium,  coma,  and  death 
follow  with  certainty  unless  operative  interference  has  relieved 
the  condition  at  a  very  early  hour  after  the  accident.  The  patient 
dies  from  shock,  hemorrhage,  or  septic  peritonitis. 

If  the  patient  is  seen  soon  after  the  accident,  before  untoward 
symptoms  have  appeared,  and  has  not  micturated  for  some  little 
time,  he  should  be  catheterized.  An  empty  bladder  will  be 
found  or  a  small  amount  of  bloody  fluid  will  be  withdrawn, 
which  rather  confirms  the  other  evidences  of  ruptured  bladder. 
If  there  is  doubt  as  to  the  rupture  of  the  bladder,  the  symp- 
toms should  be  watched.  The  symptoms  of  rupture  may  be 
masked  or  delayed  by  the  associated  lesions.  The  urine  may  be 
tinged  with  blood  because  of  a  contusion  of  the  bladder.  The 
catheter  mav  be  passed  through  the  bladder-wall,  and  be  felt  to 
enter  the  abdominal  cavity,  evacuating  bloody  fluid.     All  fluid 


PROGNOSIS  109 

havini;  been  renioNed  from  the  Ijladder,  if  a  measured  amount 
of  sterile  water  is  injected  into  it,  and  all  that  was  injected  does 
not  return,  presumption  of  rui)ture  of  the  bladder  is  very  great. 
Under  such  circumstances  the  dull  area  in  the  groins  and  lower 
abdomen  of  extraperitoneal  rupture  will  be  increased. 

Exploratory  laparotomy  should  be  done,  and  if  the  extrava- 
sation proves  to  be  extraperitoneal,  drainage  of  this  area  is  de- 
manded. Temporary  drainage  of  the  bladder,  either  urethral 
or  through  perineal  section,  will  be  needed  to  permit  healing  of 
the  bladder  wound.  The  bladder  wound  is  usually  inaccessible 
to  suture  in  these  cases. 

Prognosis. — A  guarded  prognosis  should  always  be  given  in 
any  case  of  fracture  of  the  pelvis.  Fractures  of  the  iliac  crest 
ordinarily  recover  in  a  few  weeks.  In  fractures  complicated  by 
rupture  of  the  bladder  or  bowel  the  prognosis  is  extremely  grave. 


CHAPTER   A^II 

FRACTURES  OF  THE  CLAVICLE 

Anatomy. — The  claA-icle  is  subcutaneous  throughout  its  whole 
length  (see  Fig.  124).  The  acromioclavicular  joint  is  at  its  outer 
end.     The  sternoclavicular  joint  is  at  its  inner  end.     The  clavicle 


Fig.  123. — Normal  left  clavicle  viewed  from  above. 


Fig.  124. — Muscles  arising  from  and  attached  to  the  clavicle,  showing  the  muscular  plane  in 
which  the  clavicle  lies.    X  points  to  the  coracoid  process. 


lies  in  a  muscular  plane  made  up  of  the  trapezius  and  sterno- 
cleidomastoid muscles  above,  and  the  deltoid,  pectoralis  major, 
and  subclaA'ius  muscles  below  (see  Fig.  124).     It  is  important  to 

no 


SYMPTOMS 


III 


recognize  the  sitiialion  and  the  direclion  of  the  acromioclavicular 
joint  in  order  to  discriminate  between  a  fracture  of  the  outer  end 
of  the  clavicle  and  one  of  the  acromial  process.  It  is  likewise 
important  intelligently  to  palpate  the  normal  shoulder,  to  deter- 
mine that  the  acromial  process  does  not  form  the  outer  limit  of 
the  shoulder,  but  that  it  is  formed  by  the  greater  tuberosity  of 
the  humerus. 

Symptoms. — The  common  seat  of  fracture  is  in  the  middle 
third  of  the  bone  (see  Figs.  1 25-1 28  inclusive).  The  shoulder, 
having  lost  the  support  of  the  clavicle,  falls  forward  and  drops 
inward,  consequently  the  outer  fragment  that  moves  with  the 


Fig.  125. — Fracture  at  the  inner  and 
middle  thirds  of  right  clavicle  from  above 
(Warren  Museum,  specimen  1214). 


Fig.  126. — Fracture  toward  middle  of 
clavicle,  a  little  to  the  inside  (common 
site).  Right  clavicle  from  above  (.Warren 
Museum,  specimen  987). 


Fig.  127. — Fracture  at  the  outer  and 
middle  thirds  of  left  clavicle  from  above 
(Warren  Museum,  specimen  9S7). 


Fig.  12S. — Fracture  at  the  outer  end  of 
clavicle.  Left  clavicle  from  above  (War- 
ren Museum,  specimen  7900). 


shoulder  drops  below  the  inner  fragment  and  overlaps  it  in  front. 
The  inner  fragment,  having  attached  to  it  the  sternocleidomastoid 
muscle  and  being  comparatively  free  to  move,  is  drawn  slightly 
upward.  The  attitude  of  the  patient  is  characteristic  (see  Figs. 
129,  130):  he  stands  with  the  head  inclined  to  the  injured  side, 
thus  relaxing  the  pull  of  the  sternocleidomastoid  muscle  upon  the 
inner  fragment.  The  shoulder  upon  the  side  fractured  is  de- 
pressed ;  the  elbow  and  forearm  upon  this  same  side  are  supported 
by  the  well  hand.  This  is  the  attitude  of  greatest  comfort.  The 
shoulder — i.  e.,  the  space  between  the  base  of  the  neck  and  the 
greater  tuberosity  of  the  humerus — is  shortened  upon  the  injured 
side  (see  Fig.   141).     If  the  fracture  lies  within  the  limit  of  the 


112 


FRACTURES    OF    THE    CI.AVICLE 


coracoclavicular  ligament  or  outside  of  it,  there  will  be  no  appre- 
ciable displacement  (see  Fig.  131).  The  diagnosis  under  these  cir- 
cumstances will  be  difficult.  Localized  pain  and  the  disability  of 
the  arm  will  suggest  the  lesion  present. 

Fracture  of  the  Clavicle  in  Childhood. — More  than  one-third  of 
all  fractures  of  the  clavicle  occur  in  children  under  five  years  of 
age.  A  trivial  injury  is  the  usual  cause  of  the  fracture.  A  little 
child  may  fall  from  a  low  chair  or  out  of  bed  and  fracture  the  bone. 
The  fracture  is  almost  always  incomplete  or  greenstick. 


Fig.  129.— Case  :  Comminuted  fracture  of  the  left  clavicle.    Attitude  characteristic  ;  deformity 
visible;  wired  (Mixter). 


The  child  cries  upon  moving  the  arm.  Lifting  the  child  by 
placing  the  hands  in  the  armpits  causes  pain.  The  arm  of  the 
injured  side  may  be  used  as  naturally  as  the  other  or  there  may 
be  some  disability,  perhaps  simply  a  disinclination  to  use  the  arm. 
If  the  fracture  is  greenstick,  a  tender  swelling  appears  at  the  seat 
of  the  fracture.  If  the  fracture  is  complete,  an  unevenness  will 
be  felt  at  the  seat  of  fracture  according  to  the  amount  of  displace- 
ment. The  displacement  is  usually  slight  in  childhood.  The 
characteristic  attitude  seen  in  adults  (see  Figs.  129,  130)  is  much 
less  marked  in  children,  and  if  the  fracture  is  greenstick,  there  is 


TREATMENT    IN    ADULTS 


"3 


no  tilting  of  tlic  head  and  dcjn'cssion  of  the  shoulder.  If  the  child, 
as  so  often  occiu's,  ])ersistenlly  holds  the  head  so  that  a  careful 
examination  is  impossible,  then  it  is  best  to  place  the  child  on  its 
back,  and  while  its  legs  and  arms  are  held  firmly,  the  head  and 
shoulder  may  be  gently  and  gradually  separated.  The  examina- 
tion can  then  be  completed. 


Fig.  130. — Attitude  characteristic  of  a  recent  fracture  of  the  right  clavicle. 


b       C     d 


Fig.  131. — Diagram  ot  the  ligaments  attached  to  and  near  the  clavicle  on  its  under  surface  : 
a.  Rhomboid  ;  b,  conoid;  c,  trapezoid  ;  rf,  coraco-acromial. 


Treatment  in  Adults. — The  displacement  should  be  corrected 

and  the  corrected  position  maintained  (see  Figs.  132,  133).  The 
indications  are  to  carry  the  shoulder,  and  with  it  the  outer  frag- 
ment, upward,  outward,  and  backward. 

The  Recumbent   Treatment. — The   displacement   is   most   satis- 
factorily corrected  by  the  patient  lying  recumbent  upon  a  firm 


pjg  132.— Fracture  of  the  clavicle.  Method  of  correction  of  falling  inward  and  downward 
of  shoulder,  in  overriding  of  fragments  previous  to  the  application  of  the  modified  Sayre 
dressing. 


Fig.  133-- 


-Fracture  of  the  clavicle.     Same  as  figure  132.     Posterior  view,  showing  extreme 
backward  position  of  shoulders. 
114 


Fig.  134. — Fracture  of  the  left  clavicle.  Mod- 
ified Sayre  dressing.  Towel  circular  of  upper  arm 
held  by  adhesive  plaster.  Adhesive-plaster  strap 
ready. 


Fig-  io5- — Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  applied. 
Shoulder  carried  backward.  Fixed  point 
established  above  middle  of  humerus. 


Fig.  136.— Fracture  of  the  left  clavi- 
cle. First  adhesive-plaster  strap  applied. 
Second  adhesive-plaster  strap  being  ap- 
plied. Hole  in  plaster  for  olecranon  visi- 
ble. Note  pad  for  wrist  and  folded  towel 
protecting  skin  of  arm  and  chest. 


Fig.  137.— Fracture  of  the  left  clavicle. 
First  and  second  adhesive-plaster  straps 
applied.  Pad  in  left  hand.  Shoulder 
pulled  backward  and  elevated. 


115 


Il6  FRACTURES   OF   THE   CLAVICLE 

mattress.  The  weight  of  the  shoulder  in  this  position  docs  not 
impede  reduction,  as  in  the  upright  position,  but  assists  it.  A 
firm  and  small  pillow  should  be  placed  between  the  shoulders. 
The  shoulders  fall  backward  of  their  own  weight  over  the  pillow 
carnyang  the  outer  fragment  backward  at  the  same  time.  Pad- 
ding of  the  fragments  of  the  clavicle,  the  application  of  pressure 
to  the  elbow,  may  be  more  satisfactorily  accomplished  in  the  re- 
cumbent than  in  the  upright  position.  Union  ordinarily  occurs 
within  three  wrecks.  At  the  time  of  union  or  shortly  after  the 
patient  mav  be  allowed  up  with  a  simple  retentive  dressing,  a 
sling,  and  a  swathe.  The  bed  treatment  is  hard  to  enforce  because 
the  fracture  is  the  cause  of  so  little  real  permanent  disability.  If 
there  is  much  displacement  and  deformity  can  not  be  corrected 
and  held  properly,  the  bed  treatment  is  indicated.  In  the  simul- 
taneous fracture  of  both  clavicles  the  recumbent  bed  treatment 
is  the  best  (see  Operative  Treatment  of  Fracture  of  the  Clavicle). 

The  Modified  Sayre  Dressing. — The  shoulder  and  arm  are  un- 
wieldv  in  adults.  It  is,  therefore,  necessary  in  treating  a  fracture 
of  the  clavicle  by  an  ambulatory  method  to  secure  a  very  firm 
hold  upon  the  shoulder  in  order  to  maintain  the  clavicular  frag- 
ments in  a  good  position. 

The  modified  vSayre  adhesive-plaster  dressing  is  the  best.  It 
is  applied  as  follows:  Provide  three  strips  of  adhesive  plaster, 
four  inches  wide,  and  long  enough  to  extend  once  and  a  half  around 
the  body.  The  skin  surfaces  that  are  to  come  in  contact — namely, 
the  axilla  and  chest  and  forearm — are  separated  by  compress  cloth 
and  powder.  A  dressing  towel,  folded  like  a  cravat,  is  snugly 
pinned  high  up  about  the  upper  arm  (see  Fig.  134).  This  towel 
mav  be  held  neatly  by  a  strip  of  adhesive  plaster.  One  end  of 
the  first  adhesive  strap  is  fastened  loosely  about  the  towel-pro- 
tected arm  with  a  safety-pin.  While  an  assistant  holds  the 
shoulder  well  back  the  arm  is  carried  backward,  and  held  by  the 
fastening  of  the  first  adhesive  strap  about  the  body  (see  Fig.  135). 
This  affords  a  fixed  point  at  the  middle  of  the  upper  arm.  The 
second  strap,  with  a  hole  in  it  to  receive  the  point  of  the  elbow,  is 
started  upon  the  posterior  surface  of  the  injured  shoulder  (see  Fig. 
136)  and  carried  under  the  elbow  of  the  injured  side  and  over  the 
well  shoulder  (see  Fig.  137).     The  forearm  is  flexed,  and  rests  upon 


TREATMENT   IN    CHILDREN 


117 


the  chest.  In  applying  this  second  strap  the  shoulder  is  raised 
and  the  elbow  is  carried  forward,  thus  forcing  the  shoulder  slightly 
upward  and  backward  of  the  fixed  point  used  as  a  fulcrum  (see 
Fig.  138).  A  third  strap  may  be  placed  around  the  trunk  and 
arm  to  steady  all  in  good  position.  Oyer  this  dressing  may  be 
put  a  \'clpeau  bandage  for  the  comfort  of  the  support  which  it 
affords  (see  Fig.  139).     The  adhesiye  plaster  may  be  covered  with 


Fig.  13S. — Fracture  of  the  right  clavicle. 
Modified  Sayre  dressing.  Posterior  view. 
Shoulder  elevated  and  pulled  backward. 
Folded  towel  seen  in  axilla  for  protection  to 
skin. 


Fig-  139- — Fracture  of  the  clavicle.  Method 
of  application  of  a  Velpeau  bandage.  Xote  the 
order  and  direction  ot  the  turns  i,  2,  3,4,  and  5. 
Xote  position  of  the  forearm  and  arm  of  the  unin- 
jured side. 


bits  of  gauze  bandage,  in  part  to  protect  the  skin  from  undue 
chafing,  sufficient  plaster  surface  remaining  uncovered  to  prevent 
the  straps  from  slipping.  Occasionally,  pads  (see  Fig.  140)  upon 
the  clavicle  mav  be  used  to  correct  the  deformity,  but  the  bone  is 
so  subcutaneous  that  the  skin  can  not  bear  great  pressure  without 
damage.  If  pads  are  used,  they  must  receive  frequent  inspection. 
Treatment  in  Children. — The  skin  of  the  child  must  be  pro- 


ii8 


FRACTURES    OF    THE    CLAVICLE 


tected  by  powder  and  careful  drying  before  the  arm  is  done  up. 
If  it  is  a  greenstick  fracture  and  there  is  slight  deformity,  this  de- 
formitv  should  be  corrected  by  pressure  with  the  thumbs.  An 
anesthetic  should  be  used.  After  the  deformity  is  corrected  and 
in  cases  without  deformity  it  is  necessary'  simplv  to  restrain  the 
movements  of  the  arm  for  two  weeks.  This  is  best  accomplished 
by  a  cotton  swathe  about  the  body  and  upper  arm,  held  by  straps 


Fig.  140. — Fracture  of  the  clavicle  and  subluxation  of  the  acromioclavicular  joint.  Notice 
elevation  of  shoulder  by  pressure  on  the  flexed  elbow  and  counterpressure  on  the  clavicle  by 
a  bandage  and  a  pad  (X)  placed  internal  to  the  acromioclavicular  joint. 


over  the  shoulders  and  by  a  cravat  sling.  In  warm  weather  and 
also  in  cool  weather,  for  that  matter,  the  arm  is  to  be  inspected 
frequentl}-,  as  often  as  evers*  third  day,  when  all  the  dressings  are 
removed,  the  parts  bathed  with  soap  and  w^arm  w^ater,  powdered, 
and  the  simple  retentive  dressing  reapplied.  With  this  care  only 
can  chafing  be  avoided.  If  it  is  a  complete  fracture,  the  modified 
Sayre  adhesive-plaster  dressing  should  be  used  as  in  adults.     The 


PROGNOSIS 


119 


skin  is  to  be  carefully  prolected.  and  the  dressing  most  assiduously 
watched.  It  requires  l)ut  forty-eight  hours  for  great  chafing  to 
occur  with  the  resulting  discomf(jrt  and  the  slow  healing  which 
often  results.  If  union  is  firm  after  two  weeks  or  two  weeks  and 
a  half,  the  plaster  dressing  should  be  removed  and  the  shoulder 
put  up  in  a  simple  retentive  swathe  and  sling,  at  first,  inside  the 
clothes;  after  three  weeks,  outside  the  clothes.  In  very  active 
children  the  sling  should  not  be  removed  until  four  weeks  have 
elapsed.     ^Massage  should  be  given  to  the  forearm,  elbow,  and 


Fig   141. — Fracture  of  the  riglit  clavicle.     Shortening  of  the  shoulder. 


shoulder  after  the  first  week,  together  with  passive  motion  of  the 
elbow.  In  both  children  and  adults  the  adhesive-plaster  dressing 
should  be  reapplied  at  least  once  ever\-  ten  or  twelve  days.  If  the 
dressing  chafes  or  slips,  it  may  need  more  frequent  renewal. 

Prognosis. — Useful  arms  and  shoulders  usually  result  after 
fracture  of  the  clavicle.  Almost  all  complete  fractures  of  the 
clavicle  with  displacement  of  fragments,  after  repair  has  taken 
place,  show  unmistakable  evidences  of  deformity  at  the  seat  of 
fracture,  of  shortening  of  the  width  of  the  shoulders,  and  in  manv 


I20  FRACTURES    OF    THE    CLAVICLE 

instances  in  children  of  a  slight  lateral  deformity  of  the  spinal 
column  (see  Fig.  141).  Fractures  within  the  coracoclavicu- 
lar  ligament  having  little  displacement  of  fragments  show  no 
resulting  deformity.  Very  great  deformity  does  not  preclude  a 
useful  arm.  An  ununited  fracture  of  the  clavicle  is  unusual;  it 
may  exist  and  cause  no  especial  inconvenience;  it  may  be  un- 
known to  the  patient.  An  ununited  fracture  of  the  clavicle  with 
considerable  callus-formation  may  simulate  malignant  disease  of 
the  bone.  Laboring  men  are  rarely  kept  from  their  work  more 
than  two  months.  Fractures  of  the  clavicle  in  young  children,  if 
carefully  treated,  should  unite  with  practically  no  deformity  or 
disability.  Greenstick  or  incomplete  fractures  may  show  a  general 
bowing  of  the  whole  bone,  which  it  has  been  impossible  to  correct. 

Operative  Treatment. — In  recent  fractures:  If  there  is  great 
displacement  which  can  not  be  held  reduced,  if  sharp  fragments 
threaten  vessels  or  nerves,  if  there  is  pressure  upon  either  nerves 
or  blood-vessels,  if  the  fracture  is  a  comminuted  one,  and  if  the 
bone  is  fractured  in  two  or  more  places  (multiple  fractures),  it  is 
wise  to  consider  operative  measures.  The  fragments  can  be  ex- 
posed, replaced,  and  held  in  position  by  suturing.  Good  results 
follow  this  treatment.  After  operation  for  fracture  of  the  clavicle 
a  simple  retentive  dressing  of  a  swathe  and  cravat  sling  will  be 
needed.     It  should  be  worn  for  at  least  three  weeks. 

In  Ununited  Fractures. — If  the  cause  of  delayed  union  of  the 
fracture  is  a  misplaced  bony  fragment,  an  interposed  strip  of  fascia 
or  periosteum,  or  an  interposed  subclavius  muscle,  operative 
interference  may  be  undertaken  with  a  reasonable  expectation  of 
securing  a  good  result.  If,  on  the  other  hand,  nonunion  has  ex- 
isted for  a  long  period  (a  year  or  more),  it  is  highly  probable  that 
the  ends  of  the  fragments  will  be  so  attenuated  that  refreshing 
these  ends  for  suture  would  shorten  the  fragments  to  such  an  ex- 
tent that  suture  would  be  impracticable. 


CHAPTER  VIII 

FRACTURES  OF  THE  SCAPULA 

The  spine  and  acromial  process,  the  coracoid  process,  and  the 
vertebral  and  axillary  borders  of  the  scapula  can  be  palpated  with 
comparative  accuracy.  Fracture  of  the  scapula  is  of  rather  un- 
usual occurrence,  and  always  follows  great  violence  (see  Figs.  142, 

143,  144)- 
Fracture  of  the  body  of  the  scapula  is  transverse  between 

the  axillary  and  vertebral  borders  or  comminuted  in  various  di- 
rections (see  Figs.  145,  146). 

Crepitus,  abnormal  mobility,  local  swelling,  and  tenderness  are 
present.  Pain  is  felt  upon  attempting  to  abduct  the  arm.  It 
may  be  impossible  to  raise  the  arm  to  the  head. 

Fracture  of  the  Acromial  Process  of  the  Scapula. — The 
epiphysis  of  the  acromion  unites  with  the  scapula  about  the  twen- 
tieth year.  If  there  is  a  fracture  present,  and  not  a  separation  of 
the  epiphysis,  which  sometimes  occurs,  the  line  of  fracture  is  ordi- 
narily outside  the  acromioclavicular  joint.  A  fracture  may  occur 
through  the  acromion  nearer  to  the  spine  of  the  scapula. 

Locahzed  pain,  swelling,  and  tenderness,  and  a  flattening  of  the 
shoulder  are  present.  Crepitus  may  at  times  be  felt.  If  the 
fracture  is  inside  the  acromioclavicular  joint,  the  flattening  of  the 
shoulder  will  be  considerable.  The  head  of  the  humerus  is  felt 
in  the  glenoid  cavity,  thus  ruling  out  a  dislocation. 

Fracture  of  the  neck  of  the  scapula  is  most  unusual.  If 
present,  it  may  be  mistaken  for  a  dislocation  of  the  humeral  head. 

The  acromial  process  is  prominent.  The  upper  arm  is  length- 
ened. On  lifting  the  arm  forcibly  upward  with  the  elbow  flexed, 
the  deformity  is  corrected,  and  crepitus  is  detected.  The  deform- 
ity recurs  if  this  upward  pressure  is  removed.  The  reappearance 
of  the  deformity  and  the  crepitus  serve  to  distinguish  this  injury 
from  a  dislocated  shoulder.  In  a  thin  person  palpation  of  the 
edges  of  the  glenoid  cavity  itself  will  prove  rather  satisfactory; 


Fig.  142. — Normal  scapula.     Axillary  view.  Fig.  143. — Normal  scapula.     Ventral  view. 


Fig.  144. — Normal  scapula.     Dorsal  view. 
122 


TREATMENT   OF   FRACTURES    OF   THE    SCAPULA 


123 


the  crepitus  and  aljuornuil  mobilily  can  thus  be  more  accurately 
located. 

Treatment  in  General. — Immobilization  of  the  whole  upper 
extremity,  except  the  forearm  and  hand,  is  necessary.  Localized 
pressure  may  assist  in  retaining  fragments  in  place. 

If  there  is  fracture  of  the  body  of  the  scapula,  the  forearm 
should  be  flexed  to  a  right  angle  and  held  in  a  sling.  The  skin- 
surfaces  coming  in  contact  should  be  protected  by  powder  and 
compress  cloth.     A  swathe  of  cotton  cloth  should  be  fastened 


Fig.  145.— Fracture  of  the  body  of  the 
scapula.  Bony  union  with  moderate  displace- 
ment (Warren  Museum,  specimen  8111). 


Fig.  146. — Multiple  fractures  of 
scapula.  Railroad  accident.  Man, 
forty-three  years  of  age.  Lived  one 
day  (Warren  Museum,  specimen  6028). 


about  the  upper  arm  and  trunk.  If  the  cloth  swathe  is  not  suffi- 
cient to  hold  the  scapula  steady,  a  swathe  of  adhesive  plaster 
should  be  used,  broad  enough  to  extend  from  the  acromion  to  the 
elbow. 

Fracture  of  the  Acromial  Process :  The  skin-surfaces  must  first 
be  protected  from  chafing.  The  forearm  being  flexed,  pressure 
upward  should  be  made  upon  the  elbow,  so  as  to  lift  the  arm  and 
relax  the  pull  on  the  small  acromial  fragment.  At  the  same  time 
counterpressure  is  made  upon  the  inner  fragment  and  incidentally 


124  FRACTURES    OF    THE)    SCAPULA 

Upon  the  inner  shoulder  (see  Fig.  140).  This  pressure  and  coun- 
terpressure  will  hold  the  part  reduced.  The  bandage  must  be 
inspected  frequently  each  day,  in  order  to  detect  and  to  relieve  too 
great  pressure  upon  the  elbow  and  bony  parts  of  the  shoulder. 

Union  will  take  place  in  from  three  to  four  weeks.  It  is  ex- 
tremely difficult  to  maintain  the  reduction  of  the  fragment  of  the 
acromion  by  any  apparatus.  The  one  previously  suggested  meets 
the  indications  better  than  any  other.  Massage  will  materially 
assist  in  hastening  the  absorption  of  blood  and  will  relieve  pain. 
No  very  great  functional  disability  results  if  union  occurs  with 
bony  displacement. 


CHAPTER  IX 
FRACTURES  OF  THE  HUMERUS 

FRACTURES  OF  THE  UPPER  END  OF  THE  HUMERUS 
Anatomy.— The  clavicle  may  be  felt  throughout  its  entire 
length  from  sternum  to  acromion.  The  acromial  process  of  the 
scapula  articulates  with  the  outer  end  of  the  clavicle.  This 
acromioclavicular  joint  has  an  anteroposterior  direction,  and  if 
the  line  of  this  joint  is  continued  anteriorly,  it  will  pass  down  the 


Pig_  147.— View  of  bones  of  the  shoulder  from  above.  Notice  acromioclavicular  joint,  its 
relations  to  bicipital  groove  and  coracoid  process.  The  point  of  the  shoulder  is  made  by  the 
great  tuberosity  of  the  humerus. 


front  of  the  upper  arm  (see  Fig.  147).  The  outer  edge  of  the  acro- 
mion is  continuous  downward  and  backward  with  the  spine  of  the 
scapula.  The  great  tuberosity  of  the  humerus  projects  beyond 
the  acromial  process,  and  is  covered  by  the  deltoid  muscle.  The 
point  of  the  shoulder  itself  is  made  by  the  humerus  and  not  by  the 

acromion  (see  Figs.  147,  149). 

125 


126 


FRACTURES    OF   THE    HUMERUS 


Examination  of  the  Shoulder. — The  uninjured  shoulder 
should  be  examined  before  the  injured  shoulder.  In  injuries 
doubtful  in  character,  associated  with  much  swelling  of  the 
shoulder,  and  which  are  painful  upon  gentle  manipulation,  the 
examination  should  be  made  with  the  aid  of  an  anesthetic.     Great 


Head  of  humerus. 
Glenoid  fossa. 


Fig.   148. — Transverse  section  of  trunk,  showing  obliquity   of  shoulder-joint  in   relation  to 
chest,  and  the  inclination  of  the  glenoid  cavity. 


Coracoid  process.  Clavicle. 


Acromial  process 
of  scapula. 


Head  of  humerus. 


Fig.  149. — Relations  of  bones  to  surfaces  of  shoulder  region.  Great  tuberosity  of  humerus 
projects  beyond  the  acromial  process  of  scapula.  Relations  of  coracoid  to  clavicle  and  head 
of  humerus  (compare  with  Fig.  155). 


swelling  suggests  great  trauma ;  absence  of  all  swelling  appreciable 
to  the  eye  suggests  slight  trauma. 

For  the  examination  the  patient  should  be  seated  upon  a  rather 
high  stool,  so  that  the  shoulder  comes  to  an  easy  level  for  manipu- 
lation. The  shoulder  should  be  grasped,  so  that  the  head  of  the 
humerus  can  be  felt  between  the  fingers  and  thumb  of  one  hand 


^'^M  ^1 

^k' 

-rm^M 

t^. 

>^H 

^L    '*' 

'T^^^^H 

wl 

t,^^^^^H 

w  ^ 

^^^1 

n 

Fig.  150.— Examination  of  shoulder.     Method  of  palpating  head  ol  humerus  with  thumb  and 
fingers.     Elbow  grasped  by  other  hand. 


Fig.  151.— Examination  of  shoulder.     Movements  of  the  shoulder.     Normal  maximum  abduc- 
tion.    Notice  method  of  grasping  head  of  humerus. 
127 


128 


FRACTURES    OF    THE    HUMERUS 


pressed  under  the  spinous  and  acromial  processes.  The  other 
hand  should  grasp  the  flexed  elbow  firmly,  in  order  to  make  the 
necessary  movements  at  the  shoulder-joint  (see  Fig.  150).  If 
the  head  of  the  humerus  is  intact  and  in  its  normal  place,  it  will 
be  felt  to  move  with  the  shaft  of  the  humerus,  as  upon  the  unin- 
jured side.  All  the  normal  movements  of  the  shoulder-joint 
should  be  made  passively  and  actively — naraelv,  the  movements 


Fig.  152. — Examination  of  shoulder.     Maximum  adduction.    The  bend  of  the  elbow,  when 
the  forearm  is  flexed  to  a  right  angle,  comes  to  the  median  line  of  trunk. 


of  abduction,  adduction,  forward  and  backward  swing,  and  rota- 
tion (see  Figs.  151,  152,  153).  Those  movements  which  are  pain- 
ful and  limited  should  be  carefully  noted.  Unless  the  normal 
individual  standard  of  movement  is  known,  as  determined  by  ex- 
amination of  the  well  shoulder,  there  can  be  no  definite  interpre- 
tation of  the  conditions  existing  in  the  injured  shoulder.  The 
condition  of  the  circulation  and  the  presence  of  paresis  or  paralysis 
in  the  limb  should  be  observed.     The  shaft  of  the  humerus  should 


EXAMINATION    OF    THE    SHOULDI'R 


129 


be  measured :  the  measurement  best  taken  is  the  distance  between 
the  edge  of  the  acromial  process  and  the  external  condyle  of  the 
humerus.  The  patient  should  be  seated  with  the  elbow  at  the 
side  if  possible,  and  Hexed  to  a  right  angle  (see  Fig.  154).  The 
forearm  should  rest  on  the  thigh  of  the  same  side.  The  direction 
of  the  long  axis  of  the  humerus  should  be  carefully  noted. 

The  coracoid  process  of  the  scapula  in  all  injuries  to  the  shoulder 
should  be  palpated,  for  a  knowledge  of  its  position  assists  in  locat- 


pjg_    i53._Examiiiatioii   of    shoulder.      Maximum    oulvvard    rotation.      Notice  position   of 

examining  hands. 


ing  the  head  of  the  humerus  intelligently  (see  Fig.  155).  The 
examiner  should  stand  in  front  of  the  patient,  and  place  the  left 
hand  upon  the  right  shoulder  and  the  right  hand  upon  the  left 
shoulder,  the  hands  being  open.  The  thumb  should  fall  below 
the  clavicle  a  full  finger's-breadth,  when  the  end  of  the  thumb  will 
touch  the  coracoid.  It  is  generally  possible  to  feel  the  coracoid 
even  in  very  stout  people  and  when  much  swelling  is  present. 

Diagnosis. — It  is  sometimes  impossible  to  determine  the  exact 
9 


I30 


FRACTURES    OF    THE    HUMERUS 


lesion  following  an  injury  to  the  shoulder.  Anesthesia  and  the 
Rontgen  ray  are  invaluable  aids  to  diagnosis.  It  is  of  the  first 
importance  to  know  whether  the  head  of  the  humerus  is  in  the 
glenoid  cavity  or  whether  it  is  dislocated ;  this  is  determined  by 
palpation  and  by  noting  the  direction  of  the  long  axis  of  the 
humerus.  It  is  next  in  importance  to  learn  whether  there  is  a 
fracture  of  the  humerus.     If  the  humeral  head  rotates  with  the 


Fig.  154.— Method  of  measur- 
ing the  length  of  the  shaft  of  the 
humerus  from  the  acromial  pro- 
cess to  the  external  condyle. 


Fig.  155. — Examination  ot  shoulder.  Palpating 
the  coracoid  processes.  Note  the  position  of  the  hands 
and  thumbs. 


shaft,  there  is  probably  no  fracture  unless  there  is  one  with  impac- 
tion. If  the  humeral  head  does  not  rotate  with  the  shaft,  then 
there  is  a  fracture.  If  crepitus  is  present,  the  diagnosis  is  con- 
firmed. After  injury  to  the  shoulder  the  following  fracture  lesions 
may  be  present,  and  are  to  be  considered : 


Fracture  of  the  anatomical  neck  of  the  humerus. 
Separation  of  the  upper  humeral  epiphysis. 
Fracture  of  the  surcrical  neck  of  the  humerus. 


DIFFERENTIAL    DIAGNOSIS 


131 


In  any  one  of  these  instances  a  dislocation  of  the  humeral  head 
from  the  glenoid  cavity  may  exist  and  complicate  the  case. 

Simple  Dislocation  of  the  Humeral  Head,  Subcoracoid  (see 
Fig.  156). — The  attitude  is  characteristic:  the  affected  arm  is 
held  flexed,  with  the  elbow  away  from  the  side  and  the  arm  rotated 
inward.  The  anterior  axillary  fold  is  lowered  upon  the  injured 
side.     The  long  axis  of  the  shaft  of  the  humerus  is  inclined  inward. 


Fig.  156. — Dislocation  of  the  left  shoulder.  Note  the  flat  deltoid.  Prominence  under 
coracoid.  Direction  of  the  long  axis  of  the  humeral  shaft.  Lengthening  of  upper  arm.  Left 
nipple  lowered.     Anterior  axillary  fold  lowered. 


The  roundness  of  the  shoulder  is  flattened.  The  acromial  process 
is  prominent.  The  head  of  the  humerus  is  out  of  the  glenoid 
cavity,  and  most  often  lies  under  the  coracoid  process.  The  elbow 
can  not  be  brought  in  front  tow^ard  the  median  line,  nor  can  the 
hand  of  the  injured  arm  be  placed  upon  the  opposite  shoulder. 
Active  and  passive  movements  at  the  shoulder- joint  are  greatly 
restricted.  Measuring  from  the  acromial  process  to  the  external 
epicondyle  of  the  humerus,  the  upper  arm,  in  a  subcoracoid  dis- 


132 


FRACTURES    OF    THE    HUMERUS 


location,  is  lengthened.     A  soft  crepitation  may  be  detected  in 
manipulating  the  shoulder,  which  simulates  bony  crepitus. 

Fracture  of  the  Anatomical  Neck  (see  Figs.  157,  158,  159,  160, 
161,  162). — This  is  rare.  It  occurs  in  elderly  people.  Swelling 
of  the  shoulder  is  evident.  Anesthesia  is  necessary  for  a  careful 
examination  with  deep  palpation.  There  is  thickening  of  the 
neck  of  the  bone.  Crepitus  will  be  felt  unless  the  fracture  is  im- 
pacted.    There  will  be  pain  upon  moving  the  shoulder.     Abnor- 


Fig.  157. — Fracture  of  the  anatomical  neck  ol  the  left  humerus.  Atrophy  of  the  shoulder 
muscles.  Deformity  at  the  seat  of  the  fracture,  seen  a  little  below  acromial  process  upon  the 
anterior  surface  of  the  shoulder  just  inside  the  white  line. 


mal  mobility  may  be  felt  high  up  the  shaft  close  to  the  head  of  the 
bone.     This  fracture  lies  wholly  within  the  capsule  of  the  joint. 

Separation  of  the  Upper  Epiphysis  (see  Figs.  163,  164,  165,  166, 
167). — The  separation  of  the  upper  humeral  epiphysis  will  not 
necessarily  open  the  joint  cavity,  for  the  capsular  ligament  is 
firmly  attached  to  the  epiphysis  and  the  synovial  membrane  is 
but  loosely  attached  to  the  diaphysis.  The  line  of  the  separa- 
tion of  the  upper  epiphysis  of  the  humerus  begins  on  the 
inner  side  of  the  head  of  the  bone  and  runs  across  almost  hori- 
zontally, rising  toward  the  center  of  the  shaft,  and  ends  in  the 


DIFFERENTIAL    DIAGNOSIS 


'33 


outer     side    of     the     bone,    so   that    the   epiphysis   ineJudes   the 
tuberosities. 

This  liappens  to  young  people,  but  never  after  the  twentieth 
year.  The  most  frequent  period  is  between  the  ages  of  nine  and 
seventeen  years.  Ordinarily,  the  upper  end  of  the  lower  fragment 
projects  forward  and  inward,  producing  a  characteristic  deformity. 
The  head  of  the  bone  is  in  the  glenoid  fossa,  but  rotated  by  the 
muscles  attached  to  it  so  that  its  articular  surface  looks  downward. 


Fig.  158. — Normal  right  shoulder.     Compare 
with  figure  159.     Same  case  as  figure  157. 


Fig.  159. — Fraciure  of  the  anatomical  neck 
of  the  left  humerus.  Sharp  deformity  ante- 
riorly characteristic.  Compare  with  figures 
157  and  15S. 


It  does  not  rotate  with  the  shaft.  The  crepitus  is  of  a  softer  qual- 
ity than  in  cases  of  fracture — i.  e.,  cartilaginous.  Localized  pain 
and  swelling  are  present.  A  puckering  of  the  skin,  caused  bv  the 
hooking  of  the  lower  fragment  into  the  skin  is  characteristic  (see 
Fig.  164).  Palpation  reveals  the  upper  end  of  the  shaft.  A  high 
lesion  near  the  joint  in  a  young  patient,  showing  displacement 
forward  and  inward  of  the  shaft,  is  very  suggestive  of  epiphyseal 
separation. 


\       Clavicle, 
\ 


Shaft  of  humerus. 


Fig.  i6o.— Fracture  of  high  surgical  or  anatomical  neck  of  humerus.     Recovery  with  useful 
arm.     Slight  limitation  of  movements  only  (X-ray  tracing). 


Shaft  of  humerus. 


Glenoid  cavity 
of  scapula. 


Fig.  i6i.— Fracture  of  the  anatomical  neck  of  the  humerus  (X-ray  tracing). 


134 


Fig.  162.— Man,  sixty  years  of  age.  Fracture  of  anatomical  neck  of  humerus,  six  months 
previous  to  this  (X-ray  tracing).  Backward  swing  and  abduction  slightly  limited,  otherwise 
normal  movements.    Useful  arm. 


Coracoid 

process.    Clavicle. 


—  Acromion. 

—  Epiphysis. 
--  Epiphyseal  line. 

—  Glenoid  fossa. 


Fig.  103.— Normal  shoulder,  showing  epiphysis  of  upper  end  of  humerus  (X-ray  tracing). 


135 


Fig.  164. — Separalioii  of  upper  epiphysis  of 
the  humerus  immediately  after  the  accident. 
Note,  especially,  position  of  upper  arm  and 
position  of  head,  and  deep  crease  in  skin  made 
by  the  catching  of  the  skin  in  the  upper  end  of 
the  lower  fragment.     Same  as  figure  165. 


Fig.  165. — Separation  of  the  upper  epiphysis  of 
the  humerus  (left).  Notice  shortening  of  the  upper 
arm.  Unusual  fullness  internal  and  above  normal 
position  for  head.     Same  as  figure  166. 


Fig.  166. — Separation  of  the  upper  epiphysis  of  ilic  Icfl  humerus.  Notice  prominence 
below  normal  place  for  humeral  head.  This  prominence  is  made  by  the  upper  end  of  lower 
fragment.     Same  case  as  figure  164. 

1^,6 


Fig.  167. —  Fracture  of  high  surgical  neck,  or  separation  of  epiphysis  with  rotation  of  head 
(X-ray  tracing  of  figure  164). 


Epiphysis. 


Lower  fragment 
and  callus. 


Fig.  168.— Old  fracture  of  surgical  neck  high  up,  simulating  true  epiphyseal  separation 

(X-ray  tracing). 


137 


Head  of  hu- 
merus. 


Shaft  of  hu- 
merus. 


Fig.  169. — High  fracture  of  surgical  neck,  simulating  separation  of  the  upper  epiphysis  ot 
the  humerus.  Displacement  of  lower  fragment  inward.  Old  fracture  unreduced  (X-ray 
tracing). 


Fig.  170. — Impacted  fracture  of  the  sur- 
gical neck  and  tuberosities  in  section  (War- 
ren Museum,  specimen  8539). 


Fig.  171.— Fracture  of  the  surgical  neck 
of  the  humerus.  Much  displacement.  Fi- 
brous union  only  (Warren  Museum,  speci- 
men 991). 


1^,8 


Fig.  172. — Diagram  showing 
usual  displacement  in  fracture  of 
the  surgical  neck  of  the  humerus. 


Fig-  173- — Fracture  of  the  surgical  neck 
(X-ray  tracing). 


—  Head  of  humerus. 


—  Shaft  of  humerus. 


Fig.  174. — Fracture  of  the  surgical  neck  of  the  humerus.     Displacement  of  the  shaft  outward. 
Impossible  to  reduce  without  open  incision  (X-ray  tracing)  (Eliot). 


139 


140 


FRACTURES   OF   THE   HUMERUS 


Fracture  of  the  Surgical  Neck  (see  Figs.  170,  171,  172,  173, 
174,  175). — Any  fracture  below  the  epiphyseal  line  of  the  upper 
end  of  the  humerus  and  well  within  the  upper  fourth  of  the  shaft 
of  the  bone  may,  for  all  practical  purposes,  be  regarded  as  a  frac- 
ture of  the  surgical  neck  of  the  humerus.  Fracture  of  the  surgical 
neck  is  the  common  fracture  of  the  upper  end  of  the  humerus. 
Fracture  of  the  anatomical  neck  is  most  often  seen  in  the  aged. 
Separation  of  the  upper  humeral  epiphysis  occurs  in  youth. 

The  head  of  the  bone  is  found  in  the  glenoid  cavity.  Passive 
movements  are  associated  with  pain,  and  elicit  crepitus  and  abnor- 


■~  Upper  fragment. 
--  Lower  fragment. 


/ 


Fig.  175. — Fracture  of  surgical  neck  of  the  humerus.  Same  as  figure  174  after  reduction 
by  open  incision  and  wiring  with  silver  wire.  Recovery  as  to  motion  complete  (X-ray  tracing) 
(Eliot). 


mal  mobility  at  the  seat  of  fracture,  provided,  of  course,  the  frac- 
ture is  not  impacted.  The  arm  is  slightly  shortened.  The  arm  is 
held  flexed,  with  the  elbow  at  the  side. 

If  after  an  injury  to  the  shoulder  no  positive  evidences  of  frac- 
ture or  dislocation  exist,  and  there  is  tenderness  and  localized 
swelling  about  the  joint,  and  motion  is  painful,  it  is  probable  that 
simply  a  contusion  exists. 

Treatment. — Fracture  of  the  Anatomical  and  the  Surgical  Neck 
and  Separation  of  the  Upper  Humeral  Epiphysis. — The  importance 
of  these  lesions  demands,  as  has  been  said,  an  examination  with 


I-RACTl'RES   OF    THE    UPPER    END   OF    THE   HUMERUS  141 

the  aid  of  an  anesthetic.  It  is  even  much  more  important,  how- 
ever, that  the  first  retentive  dressing  be  appHed  with  the  assist- 
ance of  an  anesthetic.  Traction,  countertraction,  and  manipula- 
tion will  secure  coaptation  of  the  fragments.  To  hold  these  frag- 
ments securelv  is  difficult.  To  hold  a  separation  of  the  upper 
epiphvsis  in  position  may  be  impossible  without  operative  assist- 
ance. To  hold  any  one  of  these  fractures  without  operative  inter- 
ference may  be  impossible. 

The  following  is  the  best  and  simplest  method  of  treatment: 
The  upper  arm,  shoulder,  and  trunk  should  be  thoroughly  pow- 
dered. The  hand,  forearm,  and  elbow  should  be  bandaged  evenly, 
smoothlv,  and  firmly  with  a  bandage  of  flannel — not  cut  on  the 
bias.  A  V-shaped  pad  (with  the  apex  of  the  V  in  the  axilla)  con- 
structed of  sheet  wadding  with  cardboard  outside  and  covered 
with  cotton  cloth,  should  be  placed  in  the  axilla  of  the  injured 
side  (see  Fig.  176).  This  pad  is  firm,  and  fitted  to  the  trunk  in 
order  to  support  the  inner  side  of  the  upper  arm  (see  Fig.  1 77).  If 
thought  wise,  a  thin  coaptation  splint  may  be  placed  between  this 
pad  and  the  inner  side  of  the  upper  arm  for  more  direct  support. 
The  forearm  is  held  flexed.  The  shoulder  is  now  well  padded  with 
one  laver  of  sheet  wadding.  A  plaster-of- Paris  shoulder-cap  is 
applied  so  as  to  cover  the  whole  shoulder,  the  anterior  and  poste- 
rior aspects  of  the  chest,  and  the  outer  side  of  the  upper  arm  down 
to  the  external  condyle  of  the  humerus  (see  Fig.  17S).  This 
shoulder-cap  is  made  of  w^ashed  crinoline,  six  layers  thick,  into 
which  has  been  rubbed  plaster-of-Paris  cream.  Its  exact  shape 
and  extent  are  seen  in  the  plates.  A  gauze  bandage  encircling 
the  trunk,  arms,  and  shoulders  should  be  used,  in  order  to  hold  the 
upper  arm  at  the  side  and  closely  applied  to  the  coaptation  splint 
and  the  axillars'  pad,  and  in  order  to  secure  the  shoulder-pad 
firmly  in  place.  Often  better  than  the  plain  gauze  bandage  is  a 
roller  bandage  of  unwashed  crinoline,  which  is  applied  just  after 
dipping  it  in  lukewarm  water  (see  Fig.  179).  The  starch  of  the 
crinoline  bandage  after  being  wet,  stiffens  the  crinoline  as  it  dries 
and  makes  a  particularly  firm  and  efficient  dressing.  A  towel 
folded  thin  or  a  piece  of  compress  cloth  should  be  placed  against 
the  trunk  upon  the  well  side.  Against  this  the  circular  turns  of 
the  bandage  rest,  thus  causing  less  discomfort  to  the  patient  than 


Fig.  176. — Fracture  of  the  upper  end  of  the  humerus.     Note  hand,  forearm,  and  elbow  ban- 
daged ;  axillary  pad  and  strap. 


Fig.  177. — Fracture  of  the  upper  end  or  shaft  of  the  humerus.     Posterior  view.     Note  bandage 
to  forearm  and  elbow ;  axillary  pad  and  strap.     Note  shape  of  axillary  pad. 

142 


FRACTURES   OF   THE    UPPER    EXD   OF   THE   HUMERUS 


143 


if  they  bear  directly  upon  the  chest.  The  forearm  is  supported 
by  a  cravat  sHng  (see  Fig.  178).  By  this  method  of  immobihza- 
tion  no  active  traction  is  exerted  upon  the  lower  fragment.  The 
weight  of  the  arm,  being  unsupported  at  the  elbow,  exerts  slight 
traction. 

On  account  of  the  absence  of  active  traction,  ambulatory  appa- 
ratus can  not  hold  a  fracture  of  the  shoulder  properly  if  there  is 
much  displacement ;  particularly  if  the  fracture  is  oblique.     Am- 


Fig.  178. — Fracture  at  upper  end  of  the 
humerus.  Note  hand,  forearm,  and  elbow 
bandaged  ;  axillary  pad  and  strap,  plaster- 
of-Paris  shoulder-cap,  sling. 


Fig.  179. — Fracture  at  upper  end  of  hu- 
merus. Arm  and  elbow  bandaged.  Axil- 
lary pad  and  shoulder-cap  in  position.  Ap- 
plication of  circular  bandage  to  trunk  and 
shoulder.     Sling  not  shown. 


bulator\"  apparatus  can  modify  muscular  action,  insure  quiet  and 
rest  to  the  part,  and,  except  in  the  instances  just  noted,  approxi- 
mately maintain  the  position  secured  by  manipulation  and  trac- 
tion and  countertraction.  On  account  of  its  limitations,  therefore, 
it  is  important  that  apparatus  should  be  removed  at  regular  and 
frequent  inten>-als  and  that  the  whole  shoulder  should  be  examined 
in  order  to  determine  errors  in  position  and,  if  possible,  to  correct 
them. 

After-care  of  a  Fracture  of  the  Shoulder. — Ordinarily,  the  great 


144  FRACTURES    OF    THE    HUMERUS 

swelling  associated  with  this  injury  disappears  in  two  weeks.  As 
the  swelling  subsides,  the  normal  contour  of  the  shoulder  becomes 
apparent  again.  It  is  necessary,  therefore,  to  alter  the  shoulder 
splint  and  to  apply  a  fresh  one.  When  the  patient  wearing  a 
shoulder-cap  lies  down,  there  is  a  tendency  for  the  shoulder-cap 
to  ride  up  and  away  from  the  shoulder.  This  can  be  guarded 
against  by  carrying  the  retaining  bandage  under  the  firm  axillary 
pad  and  well  over  the  shoulder.  Pressure  points  should  be  care- 
fully watched,  and  the  pressure  removed.  In  the  course  of  the 
treatment  of  a  single  case  this  change  of  dressing  will  have  to  be 
made  two  or  three  times.  Union  will  be  firm  in  from  three  to  four 
weeks.  As  soon  as  union  is  firm,  all  splints  may  be  omitted.  The 
forearm  should  then  be  held  by  a  sling  supporting  the  wrist.  At 
night  it  will  be  wise  to  apply  a  single  swathe  the  first  week  after 
the  apparatus  is  left  off  in  order  to  avoid  undue  motion  at  the 
shoulder  during  sleep.  In  these  injuries  about  the  shoulder- 
joint  passive  motion  should  be  made  rather  early.  At  the  end  of 
two  weeks  or  two  weeks  and  a  half  repair  will  have  proceeded  far 
enough  to  allow  of  the  gentlest  movement  at  the  shoulder  without 
causing  any  displacement  of  fragments.  The  sooner  these  gentle 
movements  can  be  resumed  at  regular  and  short  intervals,  the  more 
rapidly  the  shoulder  will  improve.  The  common  occurrence  of 
a  periarthritis  after  an  injurv  to  the  shoulder  emphasizes  the  neces- 
sity of  massage.  It  should  be  begun  as  early  as  the  second  or  third 
week. 

Prognosis  and  Result. — In  young  subjects  a  useful  arm  will 
result  (see  Fig.  i8o).  At  first,  if  there  is  great  difficulty  in  main- 
taining the  reduction  of  the  fragments,  the  surgeon  will  expect  a 
poor  result,  but  if  he  persists  in  efforts  at  retention  and  uses  pas- 
sive motion  early,  gradually  the  movements  of  the  arm  will  return 
and  to  a  surprising  degree.  In  people  past  middle  life  there 
usually  is  a  little  shortening  of  the  upper  arm  and  impairment  in 
some  few  of  movements  of  the  shoulder,  as  in  abduction  and 
external  rotation.  In  individuals  over  fifty  years  old,  excepting 
those  with  rheumatism,  a  useful  but  not  a  strong  shoulder  results 
(see  Fig.  i8i). 

The  Prognosis  in  vSeparations  of  the  Epiphysis:  Bony  union 
is  to  be  expected.     If  there  is  little  or  no  displacement  of  frag- 


FRACTURES    OF    TlIE    UPI'lCR    END    OF    THE    HUMERUS  1 45 

merits,  complete  restoration  of  function  will  result.     If  there  is 
some  deformity  rcmainin,;:;:  after  consolidation  of  the  injurv.  the 


Fig.  iSo.— Young  aduU.     Fracture  of  the  surgical  neck  of  the  humerus  (X-ray  tracing,  four 
years  after  tlie  accident).     Abduction  and  rotation  very  slightly  limited.     Useful  arm. 


^ Head  of 

\  humerus. 


Fig.  iSi. — Fracture.  Man  fifty-five  years  of  age.  High  surgical  neck  of  humerus.  Atthe 
end  of  five  years  recovery  with  very  slight  limitation  of  motion  in  all  directions.  Abduction 
is  limited  nearly  one-half.  Useful  shoulder  (X-ray  tracing.  Massachusetts  General  Hospital, 
1021). 


usefulness  of  the  shoulder  is  ultimately  and  usually  restored.     The 
deformity  becomes  less  apparent  as  the  sharp  bony  corners  are 


146  FRACTURES    OF    THE    HUMERUS 

smoothed  off  by  the  newly  forming  callus.  It  is  not  to  be  forgot- 
ten in  considering  the  prognosis  after  all  shoulder  injuries  that 
much  of  the  persisting  disability  may  result  from  too  prolonged 
immobilization  of  the  arm,  even  though  bony  displacement  may 
not  have  been  very  great.  The  growth  of  the  shaft  of  the  humerus 
in  length  proceeds  largely  from  the  upper  epiphysis.  It  has  been 
thought  by  many  that  an  arrest  of  growth  of  the  humerus  will 
follow  separation  of  this  upper  epiphysis.  It  has  been  reported 
to  have  occurred  in  eight  cases  but  in  no  others.  In  several  of 
these  cases  the  injury  to  the  shoulder  was  thought  at  the  time  to 
have  been  a  simple  contusion  or  sprain.  A  loss  of  growth  is 
not  likely  to  occur,  but  may  follow  injury  to  the  upper  humeral 
epiphysis. 

Oblique  Fracture  of  the  Surgical  Neck  with  Great  Displacement. — 
This  fracture  can  sometimes  be  held  by  placing  the  patient  in  bed 
upon  the  back  and  making  direct  traction  to  the  upper  arm  and 
countertraction  upon  the  shoulder  by  weight  and  pulley.  If  the 
fracture  can  not  be  easily  held  reduced,  it  will  be  wise  to  make  the 
closed  fracture  an  open  one  and  to  unite  the  two  fragments  by 
suture  (see  Figs.  174,  175). 

Fracture  of  the  Shoulder,  Surgical  or  Anatomical  Neck  of  the 
Humerus,  or  Separation  of  the  Upper  Epiphysis  of  the  Humerus, 
Together  with  a  Dislocation  of  the  Upper  Fragment. — The  head  of 
the  humerus  is  found  in  an  unnatural  position  and  it  fails  to  move 
when  the  arm  is  rotated.  This  is  generally  thought  to  be  an  un- 
usual accident,  but  by  careful  examination  many  of  these  cases 
may  be  detected.  During  the  attempt  at  reduction  of  a  dislocated 
shoulder,  fracture  of  the  humeral  shaft  is  liable  to  occur.  Among 
many  cases  of  fracture  of  the  surgical  neck  the  fracture  occurred 
fifty-nine  times  while  an  attempt  at  reduction  of  a  dislocation  of 
the  shoulder  was  being  made. 

Treatment. — Obviously,  attempts  at  reduction  by  manipulation 
in  the  usual  way  will  meet  with  failure.  An  attempt  should  al- 
ways be  made  to  reduce  the  dislocation  by  abduction  and  traction 
upon  the  upper  arm  and  pressure  with  the  hand  upon  the  loose 
head  in  the  axilla.  It  may  be  possible  to  reduce  the  dislocation 
in  this  manner.  If  this  method  fails,  an  attempt  should  be  made 
to  reduce  the  dislocated  head  by  open  incision  (arthrotomy)  and 


FRACTURES    OK    THIC    UPPER    END    OF    THE    HUMERUS  1 47 

manipulation  of  the  upper  fragment  assisted  by  the  McBurney- 
Porter  hook  manaaiver.  If  this  atteni])t  is  successful,  the  shaft 
should  be  sutured,  with  an  al)Sf)rbable  suture  or  fine  silver  wire, 
to  the  reduced  head,  and  the  shoulder  treated  as  if  a  closed  frac- 
ture existed. 

If  it  is  impossible  to  reduce  the  dislocated  head  or  if  the  head 
is  much  comminuted,  it  will  be  necessary  to  excise  it. 

If  operative  interference  has  been  decided  upon,  it  is  best  to  de- 
fer the  operation  until  the  acute  symptoms  have  subsided  and  the 
damaged  tissues  have  recovered  themselves.  It  is  the  result  of 
experience  that  operation  through  acutely  damaged  tissues  is  un- 
wise. The  vitality  of  the  tissues  is  lessened  by  trauma,  hence  the 
resistance  to  infection  is  temporarilv  impaired. 

If  the  reduced  head  of  the  humerus  becomes  necrosed  and  ab- 
scesses form  about  the  joint,  an  unusual  occurrence,  the  head  of 
the  bone  should  be  immediately  excised. 

The  After-treatment  of  Operated  Cases. — If  reduction  and  sutur- 
ing have  been  accomplished,  passive  motion  should  not  be  at- 
tempted until  the  repair  at  the  seat  of  fracture  is  well  under  way. 
This  will  be  about  the  second  week.  Then  gentle  movement  may 
be  made  and  gradually  increased. 

If  resection  has  been  performed,  passive  motion  should  be  gently 
begun  almost  immediately — i.  e.,  within  the  first  fort3^-eight  hours 
— and  persistently  continued.  The  muscles  of  the  shoulder  should 
be  massaged  and  treated  by  electricity.  Abduction  should  not 
be  attempted  to  any  great  extent  for  some  weeks  after  the  oper- 
ation for  fear  of  displacing  the  upper  end  of  the  humerus  too  far 
from  the  glenoid  cavity.  The  final  results  following  reduction 
and  suturing  have  been,  as  a  rule,  excellent,  useful  arms  resulting 
in  most  cases.  The  results  following  excision  are  onlv  fairly 
satisfactory.  If  the  proper  amount  of  bone  has  been  removed, 
ankylosis  will  not  occur.  If  too  much  bone  has  been  removed,  a 
dangling  or  flail  joint  will  result.  An  excision  is  to  be  avoided  if 
possible. 

FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS 
Fracture  of  the  shaft  of  the  humerus  may  occur  at  any  point 
between  the  surgical  neck  and  the  condyles  (see  Fig.  iSj).     Its 


148 


FRACTURES    OF   THE    HUMERUS 


common  seat  is  at  the  middle  or  in  the  lower  third  of  the  bone 
(see  Fig.  183).  The  twisting  force  exercised  in  the  breaking  up 
of  adhesions  in  and  about  the  shoulder-joint  will  often  fracture 
a  humeral  shaft  obliquely.  The  strength  test  of  the  arms,  as 
seen  in  the  illustration,  has  been  the  cause  of  spiral  fracture  of  the 
humerus  (see  Figs.  184,  185). 

Symptoms. — The  symptoms  are  readily  recpgnized.  They  are 
swelling  at  the  seat  of  fracture,  pain,  crepitus,  abnormal  motion, 
and  ecchymoses.     Paralysis  of  the  musculospiral  nerve  may  occur. 


Shaft  of  hu- 
merus, up- 
per frag- 
ment. 


Fig.  182. — Fracture  of  shaft  of  humerus, 
high.  Displacement  of  lower  end  of  upper 
fragment  inward  (X-ray  tracing). 


Fig.  183. — Fracture  of  the  shaft  of  the 
humerus  in  lower  third.  Displacement  of 
both  fragments  forward  (X-ray  tracing). 


with  the  characteristic  wrist-drop.  Ordinarily,  the  attention  of 
both  the  patient  and  the  surgeon  is  so  occupied  with  the  fracture 
of  the  bone  and  its  associated  loss  of  movement  that  loss  of  power 
and  sensation,  because  of  involvement  of  the  nerve,  go  unrecog- 
nized. If  injury  to  the  musculospiral  nerve  is  not  recognized  at 
the  outset,  it  may  be  overlooked  until  the  splints  are  removed. 
The  exact  duration  and  the  cause  of  the  paralysis  can  not  then  be 
readily  ascertained.  The  patient  may  wrongly  attribute  the  paral- 
ysis to  the  pressure  of  the  splints.  Very  rarely,  injury  or  pressure 
upon  the  large  vessels  of  the  arm  is  met  with.     Damage  to  the 


Fig.  1S4.— Trial  of  strength  of  arms  resulting  sometimes  in  spiral  fracture  of  the  humerus 
(Monks).     See  figure  1S5. 


/c."i'  n„, 


Fig.  185.— Illustrating  spiral  fracture  of  humerus  (Monks).    See  figure  184. 


149 


I50 


FRACTURES    OF    THE    HUMERUS 


artery  will  be  suggested  by  weak  or  absent  pulse  at  the  wrist  or 
by  local  evidences  of  hemorrhage.  A  swelling  appearing  sud- 
denly, greater  than  that  which  would  appear  from  the  laceration 
of  soft  tissues   alone,    should   suggest   rupture   of  large   vessels. 


Fig.  i86. — Longitudinal  fracture  of  shaft  of  humerus  into  the  joint.     Displacement  of  smaller 
fragment  backward.     Note  space  between  fragment  and  shaft.     Arm  extended. 


Measurement  of  the  humerus  should  be  made  from  the  edge  of  the 
acromial  process  to  the  external  condyle  of  the  humerus  (see  Fig. 
1 54) .  The  amount  of  overlapping  of  the  fragments  will  be  shown 
by  this  measurement. 


TREATMENT    OF    I-RACTl'RES    OF    THE    SHAFT 


151 


Treatment. — I'or  purposes  of  trealment,  fractures  of  the  shaft 
may  be  grouped  into  those  with  Httle  or  no  displacement  and  those 
with  considerable  displacement  and  difficult  of  retention  after  re- 
duction.    The  fracture  should  be  reduced  by  traction  upon  the 


Fig.  1S7.— Same  as  figure  186.     Note  the  disappearance  of  space  between  fragments  with  cor- 
rection of  deformity  upon  flexing  forearm.     Position  reduces  the  fracture. 


condyles  of  the  humerus  and  countertraction  upon  the  upper  arm 
and  by  manipulation  of  the  fractured  bones. 

Treatment  of  Fractures  of  the  Shaft  of  the  Humerus  with  Little  or 
no  Displacement  (see  Figs.  iS8,  189).— The  following  materials 
are  needed  for  the  apparatus  to  be  used :  Ordinary  dusting-pow- 
<ier, — which  is  powdered  oxid  of  zinc  and  powdered  starch,  equal 


Fig.  :88.— Fracture  of  the  shaft  of  the  humerus.     Note  bandage  to  hand,  forearm,  and  elbow 
axillary  pad  and  strap  ;  coaptation  splints  and  sling.     Bandage  does  not  cover  fracture. 


Fig.  189.— Fracture  of  the  shaft  of  the  humerus.  Note  bandage  to  hand,  forearm,  and 
elbow;  adhesive-plaster  swathe  holding  arm  upon  axillary  pad  and  covering  coaptation 
splints.    Sling. 


TREATMENT  OF  FRACTURES  OF  THE  SHAFT 


153 


parts ;  a  bandage  of  Shaker  flannel  three  inches  wide,  not  cut  on 
the  bias;  an  axillary  pad  made  with  several  layers  of  sheet  wad- 
ding covered  with  a  folded  piece  of  pasteboard,  and  the  whole  in- 


Fig.  190. — Space  to  be  filled  b}-  axillary 
pad  between  arm  and  side  in  fracture  of 
humerus. 


Fig.  191.— Coaptation  splint  seen  fiat 
and  in  section.  Made  by  laying  thin  wood 
on  adhesive  plaster  and  splitting  with  knife. 


Fig.  192.— Showing  effect  (bowing  outward)  of  too  short  an  axillarj  pad  upon  a  fracture  of  the 

shaft  of  the  humerus. 


closed  in  cotton  cloth  stitched  at  the  edges ;  the  pad  is  V-shaped, 
and  long  enough  to  extend  from  the  apex  of  the  axilla  to  just 
above  the  internal  condyle  of  the  humerus ;  it  is  broad  enough  to 


154  FRACTURES   OF   THE   HUMERUS 

support  the  upper  arm  comfortably  and  securely;  the  lower  part 
of  the  pad  is  about  three  inches  thick  (see  Fig.  190),  so  as  to  sup- 
port the  arm  only  a  trifle  abducted  from  the  side — that  is,  just 
away  from  the  perpendicular.  If  the  axillary  pad  is  too  short, 
there  is  danger  of  causing  an  outward  bowing  of  the  humerus  (see 
Fig.  192).  Two  straps  are  attached  to  the  upper  corners  of  the 
apex  of  the  V-shaped  pad  long  enough  to  surround  the  body  and 
go  over  the  opposite  shoulder.  These  straps  hold  the  pad  in  posi- 
tion. The  remaining  apparatus  consists  of  two  or  three  thin 
coaptation  splints  for  application  to  the  upper  arm;  these  are 


Fig.  193.— High  fracture  of  the  shaft  of  the  humerus.    A  common  and  improper  use  of  an 
internal  right-angle  splint. 

made  readily  by  laying  thin  splint  wood  upon  adhesive  plaster, 
and  splitting  the  wood  longitudinally  (see  Fig.  191);  three  adhe- 
sive straps  two  inches  wide  to  hold  the  coaptation  splints;  an 
adhesive  plaster  swathe  wide  enough  to  extend  from  the  acromion 
tip  to  the  external  condyle,  and  long  enough  to  surround  the  body 
and  upper  arm ;  a  cravat  sling ;  a  thin  towel  or  piece  of  compress 
cloth  for  the  forearm  to  rest  upon.  All  these  articles  should  be  in 
readiness. 

Etherization  of  the  patient  will  rarely  be  necessary.     In  cases 
of  nervous  and  sensitive  women  and  unmanageable  young  chil- 


TREATMENT  OF  FRACTL'RES  OF  THE  SHAFT 


155 


dron  it  will  be  wise  to  use  an  anesthetic.  The  whole  up})er  ex- 
tremity, axilla,  and  chest  should  be  waslied  w  ilh  soap  and  water, 
thoroughly  dried,  and  dusted  with  powder;  then  the  reduced 
fracture  is  held  in  position  by  an  assistant  while  the  apparatus  is 
being  applied.  The  hand,  forearm,  and  elbow  should  be  snugly 
and  evenly  covered  by  the  flannel  bandage  (see  Fig.  176).  The 
upper  arm  should  be  surrounded  by  the  coaptation  splints,  held  in 
place  by  the  three  straps  of  adhesive  plaster,  so  as  to  secure  the 
fractured  bone  perfectly  (see  Fig.  18S).  The  axillary  pad  should 
be  placed  in  the  axilla  and  held  by  the  straps  passed  over  the  oppo- 
site shoulder  and  under  the 
opposite  axilla.  The  upper 
arm  should  rest  comfortably 
upon  the  pad.  To  prevent 
chafing,  the  thin  towel  or 
compress  cloth  should  be 
placed  beneath  the  forearm 
where  it  touches  the  body. 
The  plaster  swathe  should 
then  be  applied  over  the  arm 
to  the  body,  so  as  to  encircle 
completely  the  trunk  (see  Fig. 
189).  Thus  the  arm  is  abso- 
lutely fixed  to  the  axillary 
pad  and  side.  The  wrist 
should  be  supported  in  a  cra- 
vat sling  passed  around  the 
neck.  The  elbow  is  left  un- 
supported.      The    weight    of 

the  upper  extremity  will  thus  tend  to  exert  slight  downward  trac- 
tion upon  the  lower  fragment  of  the  humerus.  Under  no  circum- 
stances should  an  ordinary  broad  sling  be  used,  because  of  the 
danger  of  making  upward  pressure  upon  the  forearm  and  elbow 
and  so  pushing  up  the  lower  fragment  of  the  humerus.  The  elbow- 
joint  should  not  be  immobilized  for  the  reason  that  it  would  then 
be  much  more  difiicult  to  hold  the  seat  of  fracture  fixed.  With 
the  elbow'-joint  fixed,  the  lower  arm  of  the  lever  is  greatly  in- 
creased, and  instead  of  movement  of  the  forearm  taking  place  at 


Fig.  194. — \'iew  of  right  humerus  from 
above,  showing  axes  of  upper  and  lower  ends. 
Head  of  bone  looks  in  the  same  general  direc- 
tion as  the  internal  condyle,  but  slightly  further 
backward.  These  relations  are  to  be  preserved 
when  treating  fractures  of  the  shaft  of  the 
humerus. 


156  FRACTURES    OF    THE    HUMERUS 

the  elbow-joint  it  would  take  place  at  the  seat  of  fracture.  Frac- 
tures of  the  shaft  of  the  humerus  are  frequently  treated  by  an  in- 
ternal angular  splint  and  coaptation  splints,  the  upper  ends  of  the 
splints  barely  reaching  the  fracture,  or,  at  best,  being  an  inch  or 
two  above  it  (see  Fig.  193).  When  the  fracture  of  the  bone  is 
within  the  lower  third  of  the  shaft,  then  and  then  only  should  an 
internal  angular  splint  be  used  in  connection  with  coaptation 
splints. 

After-treatment. — The  patient  should  be  seen  each  day  for  the 
first  three  days  in  order  that  the  surgeon  may  be  informed  as  to 
the  exact  condition  of  the  parts.  There  may  be  undue  pressure. 
The  patient  may  be  uncomfortable.  The  splints  may  need  read- 
justing. Attention  to  little  details  of  discomfort  is  important. 
The  dressing  should  be  reapplied  with  great  care  once  each  week. 
The  parts  covered  by  splints  should  at  each  dressing  be  carefully 
inspected  to  detect  any  points  of  undue  pressure,  indicated  by 
reddening  of  the  skin.  If  these  are  discovered,  they  should  be 
washed  with  alcohol  and  covered  with  flexible  collodion  or  a  dry- 
ing powder.  The  undue  pressure  should  be  removed  by  shifting 
the  padding.  Union  will  be  found  to  be  firm  after  about  three  or 
four  weeks.  As  soon  as  union  is  solid, — at  the  end  of  four  or  five 
weeks, — the  swathe  may  be  omitted,  the  coaptation  splints  alone 
being  a  sufficient  support.  After  about  five  weeks  or  five  weeks 
and  a  half  all  support  may  be  removed  from  the  arm.  The  arm  is 
then  put  in  the  sleeve  of  the  clothes,  and  the  wrist  supported  by  a 
sling.  After  eight  weeks  the  sling  may  be  discarded  and  moder- 
ate and  careful  use  of  the  limb  in  light  movements  be  indulged  in. 

Fracture  of  the  Shaft  of  the  Humerus  with  Considerable  Displace- 
ment.— Obviously,  the  method  described  for  the  treatment  of 
fractures  without  great  displacement  will  be  of  comparatively 
little  value.  Occasionally,  it  will  be  found  that  this  method  will 
hold  even  greatly  displaced  fractures ;  it  should  then  be  used.  The 
ideally  perfect  method  for  such  cases  is  traction  and  counter- 
traction  upon  the  arm  with  the  patient  lying  on  the  back  in  bed. 
Coaptation  splints  should  be  used,  as  in  simple  uncomplicated 
fractures.  If  all  methods  fail  to  hold  the  fragments  reduced,  open 
incision,  reduction  of  the  displacement,  and  suturing  of  the  frag- 
ments are  indicated. 


TREATMENT  OF  FRACTURES  OF  THE  SHAFT        1 57 

The  plaslcr-of- Paris  splint,  apjilifd  with  the  plaster  roller  to 
the  forearm  and  arm,  and  the  spica  bandage  to  the  shoulder  and 
chest  are  often  efficient  in  these  difficult  cases.  In  the  application 
of  this  splint  it  is  of  supreme  importance  that  an  assistant  hold  the 
arm  so  that  the  alineiuent  of  the  ])ones  remains  perfect.  The  as- 
sistant who  holds  the  arm  should  have  nothing  else  to  do.  Before 
applying  the  plaster-of- Paris  splint  it  is  often  advisable  to  apply 
thin  coaptation  splints  at  the  seat  of  fracture  to  give  additional 
strength  to  the  splint.  With  these  coaptation  splints  in  use  a 
lighter  plaster  splint  may  be  applied  without  sacrificing  strength. 
A  narrow  cotton  swathe  about  the  body  and  arm  should  steady 
the  upper  extremity.  The  wrist  should  be  supported  by  a  cravat 
sling". 

The  after-care  of  a  case  treated  by  the  plaster  splint  will  be 
similar  to  that  following  any  other  treatment  after  union  has  oc- 
curred. The  plaster  may  be  left  in  situ  for  four  weeks;  then, 
ordinarily,  repair  will  be  found  so  far  advanced  that  the  plaster 
splint  may  be  dispensed  with  and  the  ordinary  coaptation  splints 
and  swathe  may  be  used.  If  the  plaster  splint  has  proved  com- 
fortable, it  may  be  split  and  reapplied. 

Massage  and  Passive  Motion :  In  view  of  the  possibility  of  non- 
union of  this  fracture,  it  will  be  wise  not  to  begin  massage  until 
union  has  begun.  Passive  motion  to  the  shoulder  and  elbow 
should  be  gently  made  at  as  early  a  date  as  possible,  with  due  con- 
sideration to  the  condition  of  repair  in  the  fracture.  If  at  the 
end  of  three  weeks  union  is  found  to  have  begun,  it  will  be  wise  to 
move  the  shoulder  and  elbow  gently  by  passive  motion.  The  seat 
of  fracture  should  be  cautiously  guarded  against  movement  during 
these  gentle  manipulations.  A  little  gentle  passive  movement  of 
this  sort  repeated  occasionally  during  the  process  of  repair  will 
assist  very  considerably  in  the  restoration  of  the  functional  use- 
fulness of  the  shoulder  and  elbow,  which  so  often  become  stiff 
from  immobilization. 

Prognosis. — Ordinarily,  union  occurs  readily  in  from  four  to 
six  weeks.  In  childhood  union  is  quite  solid  in  from  three  to  five 
weeks.  Fractures  of  this  bone  are  more  likely  to  be  followed  by 
nonunion  than  fracture  of  any  other  bone  in  the  body.  The 
presence  of  abnormal  mobility  after  a  considerable  time   (three 


158 


FRACTURES    OF    THE    HUMERUS 


months)  has  elapsed  is  the  sign  of  nonunion  bA'  bone.  Considera- 
ble muscular  atrophy  follows  this  fracture  (see  Fig.  195).  Upon 
using  the  arm  again  and  by  massage  the  size  of  the  arm  is,  in  a 
great  measure,  restored.  The  stiffness  of  the  shoulder  and  elbow 
which  is  sometimes  associated  with  this  injury  is  due  to  long  im- 
mobilization without  passive  motion. 

Fracture  of  the  shaft  of  the  humerus  sometimes  occurs  in  the  new- 


Fig.  195.— Case:  Fracture  of  the  shaft  of  the  left  humerus.     Fracture  united.     Xote  atrophy 
of  upper  arm,  including  deltoid.     Loss  of  muscular  contour  very  apparent. 


born  during  delivery  or  afterward.  The  arm  is  best  immobilized 
by  thin  coaptation  splints.  These  splints  may  be  as  thin  as  six 
thicknesses  of  ordinars-  letter  paper,  and  may  be  made  of  card- 
board. The  humerus  is  completely  surrounded  by  them.  They 
are  held  firmly  by  adhesive-plaster  straps.  If  they  are  cut  the 
right  length  and  width,  they  may  be  applied  most  efficiently 
without  padding.  A  liberal  amount  of  dr\'ing  powder  should  be 
rubbed  on  the  arm  and  chest.     A  piece  of  compress  cloth  should 


MUSCUIvOSPIRAL    NERVE    INVOLVEMENT 


159 


be  placed  on  the  side  of  the  chest  under  the  injured  arm,  to  pre- 
vent chafing.  The  upper  arm  is  then  held  to  the  side  of  the  chest 
by  a  gauze  or  other  cloth  swathe.  Repair  is  rapid.  Union  is 
firm  in  about  three  weeks.  Fracture  of  the  humerus  in  the  new- 
born is  sometimes  associated  with  obstetrical  paralysis  of  the 
upper  extremity.  This  obstetrical  paralysis  should  not  be  con- 
founded with  musculospiral  paralvsis. 

The  Musculospiral  Nerve  in  Fracture  of  the  Humerus. — 
The  musculospiral  nerve  may  be  involved  in  fracture  of  the  hu- 
meral shaft,  particularly  if  the  fracture  is  at  the  middle  or  in  the 
lower  third  of  the  bone.  The  nerve  lies  in  the  musculospiral 
groove  of  the  humerus.      It  leaves  the  bone  a  little  below  the  junc- 


Fig.  196.— Relations  of  musculospiral  nerve  on  outer  side  of  arm  (from  dissected  speci- 
men) :  a.  Clavicle;  5,  deltoid;  c,  pectoralis  major;  rf,  biceps  ;  <?,  brachialis  amicus; /,  triceps  ; 
g-,  musculospiral  nerve. 


tion  of  the  middle  and  lower  thirds  of  the  arm  (see  Fig.  196).  The 
nerve  may  be  involved  primarily  at  the  time  of  the  accident  bv  the 
contusion  or  laceration  caused  by  the  original  violence  or  by  the 
pressure  of  bony  fragments.  The  ner\-e  may  also  be  involved 
secondarily  by  the  pressure  of  the  bony  callus  or  of  the  cicatricial 
tissue  of  the  soft  parts. 

Symptoms. — Contusion  of  the  musculospiral  nerce  mav  be  slight 
or  severe.  If  slight,  there  will  be  pain  at  the  injured  place,  and  a 
tingling  and  numbness  along  the  distribution  of  the  ner^-e.  These 
symptoms  may  pass  away  quickly  or  the  tingling  may  remain 
several  days.  If  it  remains,  a  chronic  neuritis  is  established 
associated  with  shooting  and  neuralgic  pains.  If  the  contusion  is 
severe,  there  will  be  complete  anesthesia  and  complete  paralysis 


i6o 


FRACTURES    OF    THE    HUMERUS 


of  the  nerve  below  the  place  involved.  This  may  pass  away  early 
or  it  may  remain  several  months  or  it  may  become  permanent. 
Pressure  upon  the  nerve  from  callus,  cicatricial  tissue,  and  bony 
fragments  will  give  signs  of  disturbed  sensation  and  motion  in  the 
parts  supplied  by  the  nerve. 

Compression  of  the  Musculospiral  Nerve:  The  musculospiral 
nerve  supplies  the  triceps,  brachialis  anticus,  supinator  longus, 
and  extensor  carpi  radialis  longior  muscles.  Inability  to  extend 
the  fingers  and  wrist  and  loss  of  supination  are  the  usual  signs  of 
motor  paralysis  following  compression  of  this  nerve.  As  for  sen- 
sation, there  will  be  complete  loss  or  impaired  sensation  in  the 


Fig.  197.— Double  fracture  of  humeral  shaft.  Immediate  musculospiral  paralysis.  Union 
of  bones  in  six  weeks.  Operation  to  free  nerve  from  lower  fragment.  Sensation  and  motion 
returned.     Same  case  as  figure  19S. 


lower  half  of  the  outer  and  anterior  aspect  of  the  arm  and  in  the 
middle  of  the  back  of  the  forearm  as  far  as  the  wrist. 

Treatment. — Immediate  paralysis  does  not  necessarily  mean 
pressure  by  a  bony  fragment.  Such  paralysis  may  be  associated 
with  contusion;  therefore,  operative  interference  should  be  de- 
layed. If  the  symptoms  persist  for  four  or  five  months,  exposure 
of  the  nerve  and  relieving,  if  possible,  the  conditions  found  are 
indicated.  It  is  wise  to  allow  the  fractured  bone  to  unite  before 
operating. 

The  prognosis  after  the  removal  of  pressure  and  following  re- 
section and  suture  of  the  musculospiral  nerve  is  good  as  to  the 
ultimate  partial  or  complete  recovery.     After  a  few  days  or  weeks 


I 


Loose  fragment  of 
shaft. 


-  Condyle  of  humerus. 


Fig.  19S.— Same  as  figure  199.     Lateral  view  to  show  displacement  of  fragment  (X-ray 

tracing). 


Upper  fragment  of 
humerus. 


Middle  loose  fragment. 


Lower  fragment. 


Fig.*i99. — Double  fracture  of  the  humerus.  Paralysis  of  the  musculospiral  nerve.  Im- 
mediate union  of  bone.  Suture  of  nerve  found  caught  between  fragments.  Gradual  recovery. 
Same  as  figure  198  (X-ray  tracing). 

II  161 


l62 


FRACTURES   OF   THE   HUMERUS 


sensation  will  return.     After  a  few  months — five  or  eight — mo- 
tion will  begin  to  return  (see  Figs.  197,  19S,  199). 

Malignant  Disease. — Carcinoma  is  said  to  have  occurred  sec- 
ondarily in  a  fractured  bone.  Sarcoma  develops  in  the  callus  of 
fractures.  It  is  highly  probable  that  in  many  of  the  so-called 
sarcomata  of  callus  the  disease  preexisted  in  the  bone,  and  was 
the  reason  for  the  fracture  occurring  after  trivial  injury. 

^H^  f)S  FRACTURES  OF  THE  ELBOW 

Fractures  of  the  lower  end  of  the  humerus  near  to  and  involving 
the  elbow-joint  are  frequent  in  childhood,  but  much  less  frequent 


Fig.  200. — The  relations  of  the  three  bony  points  at  the  elbow  in  extension  and  in  flexion 
(from  behind).  The  marks  are  placed  upon  the  internal  and  external  condyles  and  olecranon 
process  (diagram). 


in  adults.  A  familiarity  with  the  bony  landmarks  of  the  elbow 
is  essential  to  an  accurate  diagnosis.  The  more  nearly  accurate 
the  diagnosis,  the  more  efficient  will  be  the  treatment  and  the 
more  intelligent  will  be  the  prognosis.  Every  elbow  injury,  no 
matter  how  trivial,  should  be  examined  under  anesthesia. 

Method  of  Examination. — The  normal  anatomical  relations 
of  the  uninjured  elbow  are  to  be  first  determined.  The  large 
prominent  internal  condyle  of  the  humerus,  the  olecranon  pro- 
cess of  the  ulna,  the  external  condyle,  the  head  of  the  radius  are 
each  in  turn  to  be  grasped  by  the  thumb  and  forefinger.     If  these 


EXAMINATION    OF    THE    ELBOW 


163 


bony  points  can  be  recognized  upon  the  injured  elbow,  then  a 
fracture  ought  not  to  be  overlooked. 

The  Three  Bony  Points  of  the  Elbow  Region:  With  a  pencil 
or  ink  the  internal  and  external  condyles  of  the  humerus  and  the 
tip  of  the  olecranon  should  be  marked,  the  forearm  being  extended. 
Normally,  these  three  points  will  be  found  to  be  in  nearlv  a  straight 
line  transverse  to  the  long  axis  of  the  limb.  The  tip  of  the  olec- 
ranon is  a  trifle  above  this  line  (see  Figs.  200,  201 ). 

Palpation  of  the  Three  Bony  Points:  Grasping  the  left  wrist 


Fig.  201. — Normal  elbow.     Relation  of  the  three  bony  points  in  almost  complete  extension  of 
forearm.     Prominence  of  olecranon  and  two  condyles  evident. 


with  the  left  hand,  place  the  right  thumb  upon  the  external  con- 
dyle, the  third  finger  on  the  internal  condyle,  and  the  forefinger 
on  the  olecranon.  When  the  elbow  is  at  a  right  angle,  these  three 
points  will  be  found  in  the  same  plane  with  the  back  of  the  upper 
arm.  A  similar  examination  may  be  made  of  the  right  elbow, 
changing  hands  for  convenience  (see  Figs.  200,  202). 

The  Head  of  the  Radius  (see  Fig.  205) :  Grasping  the  elbow 
with  one  hand,  the  thumb  resting  one-half  an  inch  below  the 
external  condyle  upon  the  head  of  the  radius,  and  holding  the 
wrist  in  the  other  hand,  the  patient's  forearm  is  pronated  and 


Fig.  202.— Normal  elbow.     Examination.     The  three  bony  points.     Note  position  of  the 
thumb  and  two  fingers  of  the  examining  hand. 


Fig.  203.— Normal  elbows.    Well-marked  carrying  angle  apparent. 
164 


EXAMINATION    OF    THE    ELBOW 


165 


supinated.  11"  I  he  shaft  of  the  radius  is  unbroken,  the  head  of  the 
radius  will  be  felt  to  move  under  the  thumb. 

The  Carrying  Angle  (see  Figs.  203,  204) :  The  lateral  angle  that 
the  supinated  forearm  makes  with  the  upper  arm  is  called  the 
carrying  angle.  It  is  important  to  remember  that  this  angle 
varies  normally  within  very  wide  limits.  Some  individuals  have  no 
carrying  angle.    Its  presence  or  absence  is  of  little  functional  value. 

^lovements  at  the  Elbow-joint:  The  movements  of  the  joint 


Fig.  204. — Position  of  supination,  showing  the  carrying  angle.     The  outline  shows  the  position 
of  pronation  with  disappearance  of  the  carrying  angle. 


should  be  determined  both  in  flexion  and  extension.  There  is 
normally  no  lateral  motion  in  the  extended  elbow-joint.  Abnor- 
mal lateral  motion  in  either  adduction  or  abduction  should  be 
detected  if  present. 

Measurements :  The  distance  between  the  two  condyles  should 
be  measured  on  the  uninjured  arm.  The  distance  from  the  acro- 
mial process  to  the  external  condyle  of  the  humerus  should  also 
be  measured  (see  Fig.  154). 

Having  then  established  a  standard  o'f  comparison  in  the  normal 


1 66 


FRACTURES   OF   THE   HUMERUS 


elbow,  the  injured  elbow  should  be  examined  with  the  greatest 
care.  Even  when  there  is  great  swelling  of  the  elbow  region, 
steady  pressure  will  enable  the  fingers  to  reach  the  condyles.  In 
approaching  an  injury  to  the  elbow  the  questions  which  arise  are : 
Is  there"  a  dislocation?  Is  there  a  fracture?  Are  both  disloca- 
tion and  fracture  present?  Is  there  a  contusion  and  a  sprain?  Is 
there  a  subluxation  of  the  radial  head?  In  the  absence  of  positive 
signs  of  dislocation,  subluxation,  and  fracture  the  lesion  is  a  sprain 


Fig.  205. — Normal  elbow.     Method  of  examination.     Palpating  head  of  radius.     Spot  marks 

external  condyle. 


or  contusion.     In  the  absence  of  positive  signs  of  dislocation  and 
radial  subluxation  a  fracture  will  be  present. 

Summary  of  the  Order  of  Examination  of  the  Injured  Elbow. — 
Notice  whether  the  swelling  and  ecchymosis  are  general  or  localized. 
If  localized,  that  may  determine  the  seat  of  the  lesion.  Observe 
the  carrying  angle.  Palpate  the  external  and  internal  condyles 
(see  Fig.  206),  the  olecranon  process  of  the  ulna  (see  Fig.  207), 
and  the  head  of  the  radius  (see  Fig.  205).     Determine  if  crepitus 


Fig.  206.— Normal  elbow.     Method  of  examination.     Grasping  the  two  condyles  of  the 

humerus. 


Fig.  207.— Normal  elbow.     Method  of  examination.     Palpating  olecranon. 

167 


1 68  FRACTURES    OF   THE    HUMERUS 

is  present.  See  if  the  head  of  the  radius  rotates.  Note  the  rela- 
tions of  the  three  bony  points,  with  the  forearm  flexed  at  a  right 
angle  and  completely  extended  (see  Figs.  200,  201,  202).  Note 
any  lateral  motion  at  the  elbow- joint  (see  Fig.  208).  Determine 
the  possible  movements  of  the  elbow-joint.  Make  measurements. 
The  traumatic  lesions  of  the  elbow  may  be  grouped,  for  sim- 
plicity and  ease  of  reference,  in  the  following  manner.     During 


Fig.  20S.— Normal  elbow.     Line  between  the  condyles.     Method  of  examining  for  supracon 

dyloid  fracture. 


the  routine  examination  it  is  wise  to  have  in  mind  these  possible 
individual  lesions: 

Lesions  of  the  Radius  and  Ulna :  (a)  Dislocation  of  the  radius 
and  ulna  backward  with  or  without  fracture  of  the  coronoid  pro- 
cess of  the  ulna. 

(b)  Subluxation  of  the  radial  head. 

(c)  Fracture  of  the  olecranon  process  of  the  ulna. 

(d)  Fracture  of  the  neck  or  head  of  the  radius. 

lyCsions  of  the  Lower  End  of  the  Humerus :  (e)  Fracture  of  the 
internal  epicondyle  (see  Fig.  209,  c,  c). 

(/)  Fracture  of  the  internal  condyle  (see  Fig.  209,  b,  b). 


DIAGNOSIS   OF    HLBOW-JOINT   I.ESIONS 


169 


(g)    I'ractiirc  of  the  external  condyle  (see  Fig.  209,  d,  d). 

(h)  Transverse  fracture  of  the  shaft  of  the  humerus  above  the 
condyles  (supracondylar)  (see  Fig.  210,  a,  a). 

(i)  Separation  of  the  lower  epiphysis  of  the  humerus. 

(k)  T-fracture  into  the  elbow-joint  (see  209,  a,  a,  a,  and  Fig. 
210.  b,  b,  b). 

Symptoms  of  Lesions  About  the  Elboiv-joint  with  the  Differential 
Diagnosis  of  Each  Lesion. —  (a)  A  Dislocation  of  the  Radius  and 
Ulna  Backward  with  or  without  Fracture  of  the  Coronoid  Pro- 
cess of  the  Ulna :  There  may  be  very  great  swelling  of  the  region 
of  the  elbow.     The  relations  between  the  three  bony  points  are 


Fig.  209. — T-fracture,  high  {a,  a,  a). 
Fracture  of  internal  condyle  {d,  b).  Frac- 
ture of  internal  epicondyle  {c,  c).  Fracture 
of  external  condyle  [d,  d)  (diagram). 


Fig.  210.— Supracondyloid   fracture    (a,  a). 
T-fracture  low  down  (b,  b,b)  (diagram). 


disturbed.  The  olecranon  process  is  very  prominent  posteriorly. 
The  radial  head  is  displaced  backward.  The  two  condyles  are  far 
in  front  of  the  olecranon.  There  is  abnormal  lateral  mobility. 
The  normal  movements  of  the  joint  are  restricted.  This  injury 
may  be  mistaken  for  a  supracondylar  fracture.  The  important 
difference  has  been  mentioned.  A  dislocation  of  both  bones  back- 
ward, if  reduced,  does  not  ordinarily  tend  again  to  become  dis- 
placed; if  it  does,  there  is  most  likely  a  fracture  of  the  coronoid 
process  of  the  ulna. 

(6)  Subluxation  of  the  Head  of  the  Radius :  This  takes  place 
in  children  under  five  vears  of  age.     It  is  due  to  sudden  traction 


lyo  FRACTURES    OF    THE    HUMERUS 

Upon  the  extended  forearm,  which  so  often  occurs  in  Hfting  a  child 
by  the  arm  over  a  curbstone.  The  child  presents  the  arm  hanging 
slightly  away  from  the  side,  with  the  elbow  a  little  flexed  and  the 
hand  semipronated.  Attempts  to  use  the  arm  cause  pain.  The 
extremes  of  flexion  and  extension  and  supination  are  painful. 
Inspection  will  detect  a  slight  swelling  one-half  of  an  inch  to  an 
inch  below  the  external  condyle  of  the  humerus.     Tenderness  is 


Fig.  211. — Fracture  of  the  internal  condyle.     Recovery  with  "  gunstock  "  deformity,  due  to 
slipping  upward  of  fragment  and  adduction  of  forearm. 

present  over  the  head  of  the  radius.  The  relation  of  the  three 
bony  prominences  is  preserved.  The  details  of  this  not  uncom- 
mon lesion  are  mentioned  because  it  is  sometimes  mistaken  for  a 
fracture  of  the  radial  head  or  a  simple  sprain  of  the  elbow.  A  frac- 
ture of  the  radius  below  the  neck  has  also  been  mistaken  for  this 
subluxation  of  the  head.  Careful  detailed  examination  will  alone 
clear  up  any  doubts. 


DIAGNOSIS   OF    ELBOW-JOINT    LESIONS 


171 


(c)   Fracture  of  the  Olecranon  Process:  The  details  of  this  frac- 
ture are  considered  elsewhere.     Crepitus  and  mobility  of  the  olec- 


I 
/ 

Capitelluiti. ' P~J 

I 
Radius. y  - 

\ 


_.i Internal  condyle. 

\ 


\ 
Fig.  212. — Normal  right  arm  of  patient  in  figure  211  (X-ray  tracing). 


Internal  condyle. 


/ 


■ External  condyle. 

y— Capitellum. 

Radius. 


Fig.  213.— Fracture  of  interna!    condyle  of  left  humerus.    Recovery  with  deformity.    See 
figure  211  (X-ray  tracing). 


ranon  fragment  will  be  felt.  There  may  or  may  not  be  separation 
of  the  fragments.  If  there  is  a  separation,  it  will  be  detected  and 
the  three  bony  points  will  have  their  normal  relations  disturbed. 


172 


FRACTURES   OF   THE   HUMERUS 


(d)  Fracture  of  the  Neck  or  Head  of  the  Radius:  This  is  un- 
common. Swelhng  over  the  radial  head  and  neck  is  present. 
Supination  and  pronation  are  painful  and  limited  and  attended 
by  crepitus,  muscular  spasm,  and  possibly  a  loss  of  rotation  of  the 
radial  head. 

(e)  Fracture  of  the  Internal  Epicondyle :  The  epiphysis  of  this 
epicondyle  unites  to  the  shaft  of  the  humerus  between  the  eigh- 
teenth and  twentieth  years.  This  fracture  is  quite  common 
among  little  children.  If  this  fracture  presents  a  small  fragment, 
it  is  of  little  consequence.     If  a  large  fragment  is  broken  off,  it  is 


Fig.  214. — Rachitis,  showing  adduction  of  right  forearm,  as  in  figure  211. 


of  consequence.  The  displacement  is  downward  and  forward. 
The  ulnar  nerve  is  sometimes,  though  rarely,  implicated  in  this 
injury. 

(/)  Fracture  of  the  Internal  Condyle:  Swelling  over  this  con- 
dyle is  marked.  By  grasping  the  condyle  abnormal  mobility  and 
crepitus  are  detected  between  the  fragment  and  the  shaft.  The 
inner  of  the  three  bony  points  is  displaced  upward.  Lateral 
mobility  of  the  elbow  is  present;  adduction  is  especially  free. 
The  carrying  angle  will  be  diminished  if  there  is  displacement  of 
the  condyle  upward  (see  Figs.  211,  212,  213). 


DIFFERENTIAL   DIAGNOSIS 


173 


(g)  Fracture  of  the  lixternal  Condyle  (see  Fig.  215):  vSvvelling 
over  this  condyle  is  marked.  Crepitus  and  abnormal  mobility 
are  present.  The  normal  relations  of  the  three  bony  points  are 
disturbed.  The  external  condyle  is  displaced  upward.  The  re- 
lation of  the  external  condyle  and  the  head  of  the  radius  is  undis- 
turbed. Lateral  motion  at  the  elbow  is  or  is  not  present.  The 
transverse  measurement  of  the  elbow  is  greatest  on  the  injured 
side.     Supination  will  be  somewhat  limited. 

(h)  Transverse  Fracture  of  the  Shaft  of  the  Humerus  Above 
the  Condyles.  Supracondyloid  Fracture  (see  Fig.  216):  The  line 
of  this  fracture  is  higher  up  on  the  shaft  than  the  line  of  the  epi- 


-  External  condyle. 

I  — ) — J Capitellum. 

= 1 Upper  radial  epiphysis. 


Fig.  215.— Fracture  of  external  condyle  of  humerus.     Child  five  years  of  age.     Nucleus  for 
capitellum  seen  below  fragment. 


physis.  A  fullness  will  be  noticed  in  front  of  the  elbow-joint, 
and  posteriorly  the  point  of  the  elbow  will  appear  prominent. 
The  small  lower  fragment  is  displaced  backward  with  the  bones 
of  the  forearm ;  the  upper  fragment  or  shaft  of  the  humerus  is  dis- 
placed forward,  causing  the  fullness  in  the  bend  of  the  elbow  (see 
Fig.  218).  The  three  bony  points  maintain  their  normal  relations. 
This  distinguishes  the  fracture  from  a  dislocation  of  both  bones 
backward  (see  Fig.  219).  Crepitus  will  be  detected  upon  grasping 
the  arm  firmly  above  and  below  the  elbow-joint  (see  Fig.  208). 
Recurrence  of  the  displacement  often  follows  its  correction  unless 
the  fracture  is  properly  immobilized.      Abnormal  lateral  and  an- 


Fig.  216.— Case  of  transverse  fracture  above  the  condyles  of  the  left  humerus;  characteristic 
deformity.     The  anterior  deformity  is  higher  than  in  a  case  of  dislocation  of  the  elbow. 


Fig.  217.— Transverse  fracture  above  the  condyles  of  the  humerus.     Same  as  figure  216. 


DIFFERENTIAL   DIAGXOSIS 


175 


teroposterior  mobility  above  the  elbow-joint  is  found  (see  Figs. 
216,  217). 

(t)  Separation  of  the  Lower  Epiphysis  of  the  Humerus:  The 


Fig.  21S. — Supracondyloid  fracture  of 
humerus.  Elbow  flexed  to  a  right  angle. 
Diagram  to  show  displacement  of  bones. 


Fig.  219. — Dislocation  of  both  bones  of 
the  forearm  backward.  Elbow  flexed  to 
right  angle.  Diagram  showing  relative 
position  of  bones.  Compare  with  figure 
218. 


Humeral  shaft. 


_     Epiphysis. 
_    Capitellum. 


Fig.   220. — Displacement   of  lower   epiphysis  of  humerus  backward,   with   fracture   of  the 
diaphysis.     Child  seven  years  of  age  (X-ray  tracing). 


lower  epiphysis  of  the  humerus  unites  to  the  shaft  about  the  seven- 
teenth year.  It  includes  onlv  the  ver\-  lowest  end  of  the  humerus. 
The  lower  epiphysis  of  the  humerus  is  made  up  of  the  external 
epicondyle,   the   capitellum,    and  the   trochlea.     These   separate 


Shaft  of  humerus. 
Capitellum. 


Radius. 


—   Periosteum. 

!__/' ^ ,   Lower  epiphysis  of 

I  humerus. 

—       /    \  \  Ulna  shaft. 


Fig.  221. — Separation  of  the  lower  epiphysis  of  the  humerus  and  displacement  of  the  fore- 
arm inward.  Boy  nine  years  of  age.  See  figure  222  (X-ray  tracing)  (Massachusetts  General 
Hospital,  1502). 


Epiphysis 1 

I 
I 
Capitellum. 

Radius.     ~ 


Epiphysis. 

1 Shaft  of  humerus. 

i 

—  4 Ulna. 

\ 
\ 

V 

\ 

\ 
\ 


Fig.  222.— Lateral  view  of  figure  221,  showing  forward  displacement  of  the  shell  of  the 
epiphysis  and  the  lateral  displacement  of  the  ulna  (X-ray  tracing)  (Massachusetts  General 
Hospital,  1502). 

176 


DIFFERENTIAL   DIAGNOSIS 


177 


centers  of  ossification  unite  about  the   thirteenth  year,   and  at 
about  the  seventeenth  year  they  join  the  shaft  of  the  bone.     The 


Humerus. 


Detached 
periosteum.  T 


Capitelium 


Fig.  223. — Same  as  figure  221,  after  reduction.     Lateral  view.     Internal  right-angle  splint  seen 
in  position  (X-ray  tracing). 


Shaft  of  humerus. 


Epiphjsis. 


Fig.  224. — Separation  of  the  lower  humeral  epiphysis  (X-ray  tracing)  (Massachusetts  General 

Hospital,  742). 


epiphysis  of  the  internal  epicondyle  is  entirely  separate  from  the 
large,  general,  lower,  humeral  epiphysis. 

This  is  a  not  uncommon  accident.     It  occurs  usually  in  children 
12 


178 


FRACTURES    OF    THE    HUMERUS 


under  ten  years  old.     There  is  no  change  in  the  relations  of  the 
three  bony  points.     It  somewhat  resembles  transverse  fracture 


—  Shaft  of  humerus. 

Lower  humeral  epiphysis  and 

bits  from  the  diaphysis. 

—  Capitellum. 


Fig.  225. — Separation  of  the  lower  humeral  epiphysis.  Child  nine  years  of  age.  Separa- 
tion reduced.  Capitellum  and  epiphysis  distinctly  seen  in  the  lateral  view.  Internal  angular 
tin  splint  shown. 


Olecranon  fossa. 

Internal  portion  of 
epiphysis. 


Ulna. 


Humeral  epiphysis  and 
bits  from  the  diaphy- 
sis. 

Capitellum. 

Radial  epiphysis. 


—   Radius. 


Fig.  226. — Separation  of  the  lower  epiphysis  of  the  humerus,  after  union.  Anteroposterior 
view.  This  figure  illustrates  the  fact  that  the  epiphysis  does  not  include  the  condyles  of  the 
humerus  (X-ray  tracing). 


above  the  condyles.     The  diagnosis  is  made  upon  the  following 
points:  The  age  of  the  individual;  the  history  of  the  accident; 


DIFFERENTIAL    DIAGNOSIS 


179 


the  existence  of  abnormal  mobility  at  a  very  low  level  on  the 
humeral    shaft;  anteroposterior    mobility    very    marked,    lateral 

mobilitv  being  less  marked ;  muffled  crepitus  (this  term  is  very 


1     I 


United  humeral 

epiphysis. 
Capitellum. 


r 

1 

Radial  epiphysis. 

Fig.  227. — Separation  of  the  lower  humeral  epiphysis,  after  union.    Lateral  view.    Extension 
normal.    Flexion  to  a  right  angle  (X-ray  tracing)  (Massachusetts  General  Hospital,  1556). 


Fig.  22S.  —  Compound 
fracture  of  elbow — T-frac- 
ture — following  epiphyseal 
lines  in  part.  Boy  of  about 
nine  years  of  age.  Forearm 
also  extensively  injured. 
Amputation. 


Fig.  229. — T-fracture  of 
elbow.  Man  of  fortj'-five, 
fell  twenty  feet  and  struck 
elbow,  producing  com- 
pound fracture.  Arm  am- 
putated (Warren  Museum, 
specimen  999). 


Fig.  230. — T-fracture  of 
humerus,  low  down.  Man 
of  forty-eight,  fell  down- 
stairs. Arm  amputated 
(Warren  Museum,  speci- 
men 1102). 


suggestive,  and  is  used  by  Poland).  The  breadth  of  the  lower  end 
of  the  humeral  fragment  is  broader  than  in  the  case  of  a  fracture 
(see  Figs.  220  to  227  inclusive). 


i8o 


FRACTURES    OF    THE    HUMERUS 


(k)  T-fracture  into  the  Elbow-joint  (see  Figs.  228,  229,  230): 
The  traumatism  which  causes  this  injury  may  be  extremely  slight. 
If  the  two  condyles  are  grasped,  crepitus  and  abnormal  mobility 
will  be  detected.  The  relations  of  the  three  bony  points  will  be 
disturbed,  according  as  one  or  both  condyles  are  displaced.  The 
transverse  measurement  of  the  condyles  will  be  found  to  be  in- 


Fig.  231. — Method  of  manufacture  of  tin  internal  right-angle  splint:  a.  Form  into  which 
piece  of  tin  is  folded  (with  vise  and  hammer) ;  d  shows  the  bend  in  the  back  ridge  completed 
(bent  with  pliers,  hammered  close  in  the  vise)  ;  c,  the  completed  splint  with  edges  shaped  and 
covered  with  adhesive  plaster,  and  with  the  surfaces  of  the  splint  properly  concaved. 


Fig.  232. — Patterns  of  pieces  used  in  making  the  usual  (soldered)  internal  right-angle  splint, 
seen  applied  in  figure  242. 


creased.     There  will  be  abnormal  lateral  mobility,  both  in  adduc- 
tion and  abduction. 

A  systematic  anatomical  examination  of  injuries  to  the  elbow 
under  an  anesthetic  will  overcome  much  of  the  indefiniteness  that 
surrounds  these  injuries.  A  crushed  elbow,  feeling  to  the  ex- 
amining hand  like  a  bag  of  bones,  can  not  always  be  accurately 


TREATMENT  OF  FRACTURES  OF  THE  ELBOW 


I8l 


diagnosed,  some  of  the  details  of  the  lesions  naturally  remaining 
undetermined.  The  Rontgen  ray  in  these  doubtful  cases  will  be 
of  material  assistance.  The  importance,  however,  of  making  such 
a  careful  eliminative  examination  as  is  described,  both  from  the 
point  of  view  of  treatment  and  prognosis,  can  not  be  overesti- 
mated. 

Treatment. — The  object  of  treatment  is  to  restore  the  elbow- 
joint  to  its  normal  condition.  If  the  fracture  is  attended  by  great 
swelling,  it  will  be  necessary  to  temporarily  support  the  arm  until 


%Wo^ 


Fig.  233.— Supracoiidyloid  fracture  of  the  humerus.  Method  of  reduction  before  applying 
retentive  splint.  Countertraction  on  upper  arm.  Traction  on  condyles  of  humerus  with  right 
hand  ;  backward  pressure  with  thumb  of  left  hand.  Also  illustrative  of  method  of  beginning 
acute  flexion. 


the  swelling  reaches  its  maximum  and  begins  to  subside.  The 
right-angle  internal  angular  splint  is  the  most  satisfactory  for  this 
purpose  (see  Figs.  231,  232).  The  maximum  swelling  will  have 
taken  place  after  forty-eight  to  seventy-two  hours.  This  tem- 
porary dressing  will  rarely  be  needed.  In  general,  it  may  be  stated 
that  the  arm  should  be  placed  in  that  position  in  which  it  is  found, 
upon  experiment  with  the  fracture  under  consideration,  that  the 
fragments  are  best  held  reduced. 

Fractures  of  the  internal  epicondyle,  of  the  internal  condyle,  of  the 


l82 


FRACTURES   OF    THE    HUMERUS 


external  condyle,  and  T-fractures  into  the  joint  are  best  treated,  as  a 
rule,  in  the  acutely  flexed  position. 

Experimental  evidence,  both  upon  the  cadaver  and  on  the 
anesthetized  living  subject,  confirmed  by  clinical  experience  ex- 
tending over  a  number  of  ^^ears  in  the  hospital  and  private  practice 
of  many  different  surgeons,  demonstrates  that  the  acutely  flexed 
position  actively  reduces  and  holds  reduced  the  fractures  previ- 


Fig.  234. — Left  elbow  in  position  of  forced  flexion.  Gauze  in  bend  of  elbow.  Thin  axillary 
pad.  Pad  under  hand  and  wrist.  Gauze  protection  under  forearm,  held  by  safety-pin  from 
slipping.  Adhesive  plaster  maintaining  flexion.  Skin  protected  on  upper  arm  by  gauze  com- 
press from  cutting  of  adhesive  plaster. 


ously  mentioned.  In  the  acutely  flexed  position  the  coronoid 
process  in  front,  the  trochlear  surface  of  the  olecranon  behind,  and 
the  fasciae  posteriorly  and  laterally,  together  with  the  tendon  of 
the  triceps  posteriorly,  hold  the  fragments  reduced  and  close  to  the 
shaft  of  the  humerus. 

Method  of  Using  the  Acutely  Flexed  Position :  The  condyles  of 
the  humerus  are  grasped  by  the  thumb  and  finger  of  one  hand, 


TREATMENT   OF   FRACTURES   OF   THE   ELBOW 


183 


a  fins^cr  of  llif  oIIkt  hand  is  placed  in  \hv  bend  of  Ihe  elbow,  trac- 
tion is  nuidc  upon  the  forearm,  and  it  is  slowly  flexed  to  an  acute 
angle.  While  the  forearm  is  being  flexed,  traction  and  lateral 
pressure  are  brought  to  bear  upon  the  loose  fragments  of  the 
humerus  to  correct  existing  malpositions.  These  manipulations 
will  materially  assist  in  the  reduction  (see  Fig.  233). 

The  degree  of  flexion  will  be  determined  by  the  obstruction 


Fig.  235. — Applying  figure-of-eight  cravat  to  flexed  elbow 
(after  Lund). 


Fig.  236. — Strap  from 
elbow  to  cravat  to  prevent 
abduction  of  flexed  elbow. 


offered  by  the  local  swelling.  If  the  swelling  is  great,  or  is  likely 
to  increase  very  much,  then  the  degree  of  flexion  must  be  less  than 
when  there  is  no  swelling.  In  the  bend  of  the  elbow,  to  prevent 
chafing,  is  placed  a  piece  of  gauze  upon  which  has  been  dusted 
a  dry  powder.  This  acutely  flexed  position  is  maintained  by  an 
adhesive-plaster  strap,  three  inches  wide,  passing  about  the  arm 
and  forearm  (see  Fig.  234).     This  strap  should  be  placed  upon  the 


1 84 


FRACTURES    OF    THE    HUMERUS 


Upper  arm  as  high  as  the  axillary  fold,  and  upon  the  forearm  just 
above  the  styloid  of  the  ulna.  A  piece  of  linen  or  compress  cloth 
(cotton  cloth)  is  placed  under  the  forearm  and  hand  where  they 
would  come  in  contact  with  the  skin  of  the  chest.  This  should  be 
pinned  so  as  not  to  slip  from  position.  The  arm  thus  flexed  is 
supported  by  a  swathe  sling  (see  Fig.  235)  made  of  cotton  cloth, 


Fig.  237. — Fastening  figure-of-eight  cravat  over  folded 
compress  on  opposite  side  of  chest.  Elbow  region  open  to 
inspection. 


Fig.  238. — Adhesive 
plaster  strip  showing 
bits  of  gauze  arranged 
so  as  to  protect  skin 
from  plaster  without 
impairing  efficiency  of 
the  plaster. 


fifteen  inches  wide,  folded  three  times,  and  long  enough  to  extend 
twice  around  the  body.  This  is  applied  as  illustrated  (see  Figs. 
235,  236,  237).  The  elbow  is  held  to  the  side  by  pinning  a  strip  of 
compress  to  the  swathe  at  the  elbow  and  posteriorly  (see  Fig.  236). 
Precautions  in  Using  the  Acutely  Flexed  Position:  The  arm  is 
inspected  each  day  for  the  first  week.     It  is  necessary  to  note 


TREATMENT  OF  FRACTURES  OF  THE  ELBOW        1 85 

whether  with  the  increase  in  the  swelHng  the  flexion  of  the  arm 
should  be  diminished,  and  whether  with  diminution  in  the  swell- 
ing flexion  may  be  increased  with  safety.  The  radial  pulse  should 
be  felt  as  the  flexion  is  diminished,  so  as  to  avoid  compression  of 
the  vessels  at  the  bend  of  the  elbow.  There  should  be  no  pain 
associated  with  this  acutely  flexed  position.  A  certain  amount 
of  discomfort  may  be  complained  of.  Real  pain  will  be  indicative 
of  too  great  pressure,  and  if  it  is  present,  the  forearm  should  be 
less  acutelv  flexed.     Chafing  should  be  looked  for  at  the  bend  of 


Fig.  239. — Fracture  of  the  elbow.  Application  of  the  internal  right-angle  splint.  First 
strap  already  applied.  Manner  of  holding  splint  and  arm  as  the  forearm  is  flexed  up  to  the 
splint  (see  Fig.  240). 


the  elbow,  under  the  forearm  and  hand  and  on  the  chest,  where, 
if  necessary,  fresh  powder  and  compress  cloth  should  be  placed. 
The  edge  of  the  adhesive  plaster  may  cause  chafing  of  the  skin 
upon  the  posterior  surface  of  the  forearm  and  upper  arm.  It  may 
be  necessary  to  place  beneath  the  plaster  small,  carefully  folded 
compresses  of  cotton  cloth  to  protect  the  skin  (see  Fig.  235). 

Later,  in  changing  the  adhesive  plaster,  the  skin  may  be  washed 
with  alcohol  and  then  with  soap  and  water,  to  the  great  comfort 
of  the  patient.     The  alcohol  removes  all  adhesive  plaster  sticking 


1 86 


FRACTURES    OF    THE    HUMERUS 


to  the  skin.  If  the  adhesive  plaster  chafes  the  skin,  as  it  so  often 
does  in  children,  it  will  be  necessary  to  place  a  bit  of  gauze  under 
the  adhesive-plaster  strips,  leaving  enough  of  the  sticky  side  of 
the  plaster  uncovered  to  catch  the  skin  and  thus  keep  it  from  slip- 
ping entirely  loose.  The  carr\'ing  angle  of  the  arm  will  be  pre- 
serv^ed  if  the  fragments  are  approximately  reduced;  it  can  not 
be  maintained  otherwise.  The  acutely  flexed  position  reduces 
the  fragments  in  the  fractures  tmder  consideration;  therefore  it 
will  preser\-e  the  carrying  angle. 

Transverse  Fracture  of  the  Shaft  above  the  Condyles. — There  is 


Fig.  240. — Fracture  of  the  elbow.     Application  of  the  internal  angular  splint.     Placing  second 
strap.     The  angle  of  the  splint  is  crowded  into  the  bend  of  the  elbow  (see  Fig.  239). 


usually  an  overlapping  of  the  fragments.  This  is  eA"ident  in  the 
backward  displacement  of  the  lower  fragment  and  forearm  and  in 
the  forward  displacement  of  the  upper  fragment. 

It  will  be  necessary  in  order  to  effect  reduction  of  this  fracture 
to  make,  with  the  aid  of  an  assistant,  countertraction  and  pressure 
backward  upon  the  upper  fragment  while  traction  and  a  forward 
pull  are  made  upon  the  lower  fragment  by  grasping  the  arm  above 
the  condyles  (see  Fig.  233).  The  internal  right-angle  splint  will 
best  hold  this  fracture,  for  it  exerts  continuous  pressure  backward 
upon  the  upper  fragment  and  prevents  displacement  (see  Figs. 
239,  240 j.     It  is  padded  with  sheet  wadding  and  applied  as  iUus- 


TREATMENT  OF  FRACTURES  OF  THE  ELBOW 


.87 


tralt'd.  Two  straps  arc  needed  upon  the  forearm  to  hold  this 
splint  in  good  position  (see  Figs.  241,  242).  The  strap  at  the 
wrist  should  be  so  applied  that  there  is  no  pressure  upon  the  sty- 
loid process  of  the  ulna.  Long-continued  pressure  upon  this  bony 
process  would  cause  a  pressure  sore.  In  applying  the  adhesive 
plaster  it  is  wise  to  apply  it  so  loosely  that  there  is  no  undue  pres- 
sure upon  the  arm.  which  might  retard  the  circulation.  The  arm 
is  then  covered  with  a  roller  bandage  of  sheet  wadding,  over  w'hich 
is  placed  a  roller  bandage  of  cheese-ck)th.  This  should  be  applied 
smoothly  and  lirmly  from  the  hand  to  the  upper  end  of  the  splint. 


Fig.  241. — Two  straps  insufficient  to  hold 
elbow  in  internal  right-angle  splint.  Splint 
has  slipped  away  from  the  bend  of  the  elbow. 


Fig.  242. — Third  strap  is   necessary  to  hold 
the  splint  close  to  the  flexed  elbow. 


As  the  swelling  about  the  elbow  begins  to  subside,  pads  of  cotton 
cloth  (compress  cloth)  may  be  placed  at  each  side  of  the  olecranon 
below  each  condyle.  The  pressure  of  a  frequently  renew^ed  ban- 
dage on  these  pads  wall  hasten  the  disappearance  of  the  swelling. 
It  is  important  to  avoid  the  forward  and  backward  deformity  in 
treating  this  fracture  (see  Figs.  243,  244,  245). 

Dislocation  of  Both  Bones  of  the  Forearm  Backward. — If  there 
is  no  tendency  to  displacement  after  reduction  is  accomplished, 
the  right-angle  position  with  internal  splint  is  the  best  treatment. 
If,  on  the  other  hand,  there  is  a  tendency  to  displacement,  the 
acutely  flexed  position  will  be  the  best  for  the  arm  because  in 


l88  FRACTURES    OF    THE    HUMERUS 

case  the  coronoid  process  is  broken  it  will  insure  its  close  approxi- 
mation to  the  ulna. 

Separation  of  the  lower  epiphysis  of  the  humerus  will  be  best 
treated  in  the  right-angle  position,  the  same  as  a  fracture  of  the 
humerus  above  the  condyles  (see  Figs.  223  and  225). 


Fig.  243. — Supracondyloid  fracture.  Ob- 
liquity of  the  line  of  fracture  from  behind 
downward  and  forward.  Diagram  show- 
ing anterior  deformity  with  elbow  flexed. 


Fig.  244. — Supracondyloid  fracture.  Ob- 
liquity of  the  line  of  fracture  from  above 
downward  and  backward.  Diagram  show- 
ing posterior  deformity  if  acute  flexion  of 
forearm  is  attempted. 


Fig.  245. — Supracondyloid  fracture  with  slight  anterior  displacement,  wired.  Recovery, 
with  slight  anterior  bending  of  fragments.  Wire  seen  zh  izVz(  (X-ray  tracing.  Massachusetts 
General  Hospital,  1077). 


Fracture  of  the  neck  of  the  radius  is  best  treated  by  the  internal 
right-angle  splint. 

Fracture  of  the  olecranon  is  discussed  elsew^here. 

The  After-care  of  Injuries  to  the  Elbow. — The  reapplying  of 
splints  and  of  apparatus  should  be  done  often  enough  to  be  sure 


THE   PROGNOSIS   OF    FRACTURES   OF    THE    ELBOW  1 89 

that  thev  are  efficient,  and  that  there  is  no  undue  swelling  or  pres- 
sure upon  the  arm.  Rebandaging  the  hand  and  the  arm  each  day, 
if  the  internal  angular  splint  is  used,  is  important.  All  apparatus 
should  be  removed  at  least  once  a  week,  and  carefully  inspected 
twice  during  this  interval.  Passive  motion  should  be  instituted 
late  rather  than  early.  In  most  instances  it  will  be  wise  to  delay 
passive  motion  until  union  is  firm — from  the  fourth  to  the  sixth 
week.  It  should  be  of  the  gentlest  sort;  passive  motion  that  is 
painful  does  harm. 

Massage  to  the  hand,  wrist,  forearm,  elbow,  and  upper  arm, 
after  the  primary  swelling  has  begun  to  subside,  is  of  great  value. 
It  should  be  given  at  first  without  disturbing  the  apparatus  and 
the  retentive  adhesive  plaster.  Given  every  other  day,  it  will 
accomplish  considerable  in  maintaining  the  integrity  of  the  mus- 
cles of  the  part.  The  employment  of  a  professional  masseuse  is 
not  always  necessary.  The  physician  should  give  the  massage  or 
instruct  a  competent  person  how  to  give  it. 

Omission  of  Splint  or  Retentive  Apparatus:  This  should  be 
tentative  and  gradual  after  union  is  known  to  be  firm — in  the 
fifth  or  sixth  week.  The  arm  should  be  allowed  in  a  sling  without 
the  splint  for  an  hour  and  then  the  splint  applied.  The  follow- 
ing day  a  longer  interval  is  granted  without  the  splint.  Gradu- 
ally, the  splint  is  removed  entirely.  A  snugly  fitting  bandage 
will  often  prove  comfortable  as  a  support  on  first  leaving  oflf  the 
splint.  Passive  motion,  massage,  and  active  use  of  the  arm  will 
now  assist  in  regaining  the  use  of  the  joint.  At  this  stage  the 
carrying  of  dumb-bells,  pails  or  baskets  filled  with  sand,  and  the 
doing  of  certain  gymnastic  movements  with  the  injured  arm 
wull  be  of  material  aid.  All  violent  exercise  of  the  part  is  to  be 
avoided.  That  amount  of  exercise  may  be  allowed  that  leaves 
the  arm  moderately  tired.  A  fatigue  that  is  not  recovered  from 
within  a  half-hour's  rest  is  excessive. 

The  Prognosis. — Up  to  the  time  of  the  present  introduction 
of  the  acutelv  flexed  position  in  the  treatment  of  fractures  at  the 
elbow,  the  movement  most  easily  lost  and  with  greatest  difficulty 
regained  was  that  of  flexion.  By  the  use  of  the  acutely  flexed 
position  in  suitable  cases  the  prognosis  has  improved  remarkably 
in  this  respect.     Xow  all  of  flexion  is  ordinarily  preserved,  and 


190 


FRACTURES    OF    THE    HUMERUS 


the  more  easily  acquired  extension  is  obtained  as  usual,  so  that 
the  prognosis  as  to  motion  in  these  cases  is  good.  Although  ana- 
tomically perfect  results  are  not  always  obtained,  most  fractures 
of  this  region  recover  with  a  useful  arm.  These  fractures  of  the 
elbow  region  should  be  kept  under  observation  for  at  least  four 
months.  It  is  wise  to  treat  such  cases  until  all  that  can  be 
achieved  toward  a  restoration  of  function  has  been  accomplished. 
At  the  time  of  the  first  examination  of  the  elbow  the  nature  of 


Fig.  246. — Diagram  to  show  the  amount  of  the  limitation  of  extension  that  may  be  caused 
by  very  moderate  callus  (a)  in  the  olecranon  fossa,  without  displacement  of  fragments  (median 
section  of  dry  bones). 


the  injury  and  its  seriousness  should  be  explained  carefully  to 
the  patient  or  his  friends.  A  guarded  outlook  should  be  ex- 
pressed, particularly  with  reference  to  the  function  of  the  joint. 
Some  limitation  of  motion  may  exist  after  all  that  is  possible  has 
been  done  (see  Fig.  246).  How  much  limitation  of  motion  will 
exist  it  is  impossible  to  state.  There  may  be  none  whatever. 
The  patient  and  his  friends  should  be  encouraged  with  the  state- 
ment that  just  as  great  usefulness  of  the  elbow-joint  will  be  ob- 


THE    PROGNOSIS   OF    FRACTURES   OF    TIIE    ELBOW  191 

tained  as  is  Cdiisislcnt  witli  llic  character  of  the  injury.  'Jhe 
importance  of  the  injury  demands  of  every  physician  a  painstak- 
ing anatomical  examination  with  the  aid  of  an  anesthetic,  careful 
attention  to  minute  details  in  the  initial  treatment,  and  intelligent 
solicitude  in  the  after-care  of  all  traumatisnis  to  the  elbow-joint.  ''         >''^ 


CHAPTER  X 
FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

FRACTURES  OF  BOTH  RADIUS  AND  ULNA 

The  most  common  seats  of  fracture  are  in  either  the  middle  or 
lower  thirds  of  the  bones.  The  fracture  of  the  radius  is  often  a 
little  higher  than  the  fracture  of  the  ulna  (see  Figs.  247-251  inclu- 
sive). 

Symptoms. — The  arm  can  not  be  used  without  pain.  In  a 
muscular  or  fat  arm  with  little  separation  of  the  fragments  there 
may  be  no  deformity  excepting  the  localized  swelling  of  the  seat 
of  fracture.  Deformity  will  be  determined  by  the  displacement  of 
the  bones.  If  the  seat  of  fracture  is  not  obvious,  the  forearm 
should  be  grasped  by  the  two  hands  (see  Fig.  252)  and  gentle  but 
firm  movement  attempted,  to  determine  the  presence  of  abnor- 
mal motion  and  crepitus.  Motion  should  be  attempted  in  all 
directions,  for  the  bones  may  be  fractured  and  yet  be  locked  when 
movement  is  made  in  one  direction  only. 

Incomplete  or  Greenstick  Fracture  of  the  Bones  of  the 
Forearm  (see  Figs.  253,  254,  255). — This  is  a  partial  break  across 
the  bone,  with  bending  at  the  seat  of  fracture.  In  children  be- 
tween the  ages  of  two  and  fourteen  years  injury  to  the  bones  of 
the  forearm  results  usually  in  a  greenstick  fracture.  Either  one 
or  both  bones  may  be  broken.  One  bone  may  be  completely 
fractured  while  the  other  is  incompletely  broken. 

Deformity  is  very  evident.  Pain  and  tenderness  at  the  seat  of 
fracture  are  present.  Crepitus  is  absent  unless  one  bone  is  com- 
pletely fractured.  Children  having  these  fractures  are  often  seen 
a  week  or  two  after  the  injury;  they  are  said  to  have  "sprained 
the  arm"  and  "are  unable  to  use  it  well  at  the  present  time." 
Careful  inspection  will  detect  the  characteristic  bowing  at  the 
seat  of  a  greenstick  fracture.  Slight  callus  will  be  present  if  a 
little  time  has  elapsed  since  the  injury. 

192 


13 


193 


194 


FRACTURES  OF  THE  BOXES  OF  THE  FOREARM 


Fracture  of  the  Neck  and  Head  of  the  Radius. — These  frac- 
tures are  rarelv  unassociated  with  lesions  of  the  humerus  and 

ulna.  A  fracture  of  the  external  condyle  of  the  humerus  and 
backward  dislocation  of  both  bones  of  the  forearm  have  been 
noted  with  these  fractures. 

Local  swelling  and  tenderness  over  the  radial  head  and  neck  are 
apparent.  The  swelling  is  greater  than  in  a  simple  subluxation 
of  the  radius,  and  is  limited  to  the  upper  third  of  the  radial  side 
of  the  forearm.  There  is  pronation  of  the  forearm.  Flexion  and 
extension,  in  the  absence  of  associated  lesions  such  as  fracture  of 


Fig.  248. — Fracture  of  both  bones  of  the 
forearm  near  the  wrist,  at  about  the  same 
level.  Radial  displacement  of  whole  hand. 
Deformity  of  wrist  resembling  somewhat 
that  of  Colles'  fracture  (X-ray  tracing). 


Fig.  249. — Fracture  of  both  bones  of  the 
forearm  near  the  wrist ;  different  levels.  Xo 
displacement  in  either  place  (Massachusetts 
General  Hospital,  1384.     X-ray  tracing). 


the  external  condyle  of  the  humerus,  are  possible.  Attempted 
rotation  of  the  radius, — that  is,  supination, — elicits  pain,  muscular 
spasm,  and  perhaps  crepitus.  The  head  of  the  bone  does  not 
usually  rotate  with  the  shaft,  at  least  not  as  it  does  normally. 
vSubluxation  of  the  radial  head  and  fracture  of  the  external  con- 
dyle of  the  humerus  are  the  two  lesions  with  which  a  fracture  of 
the  radial  neck  and  head  is  most  often  confused.  The  points  of 
difference  have  been  indicated.  The  X-ray  is  here  of  decided 
value.  It  is  often  difficult  on  account  of  overlying  muscle  and 
swelling  of  the  soft  parts  to  palpate  the  head  of  the  radius  with 


FRACTURES    OF    BOTH    RADIUS    AND    ULXA 


195 


accuracy.  Pressure  over  the  shaft  of  the  radius  at  about  its  mid- 
dle elicits  pain,  if  a  fracture  of  the  radial  neck  l)e  present,  at  the 
seat  of  fracture.  An  X-ray  of  the  elbow  will  determine  a  diagno- 
sis. 

Fracture  of  the  Shaft  of  the  Radius  (see  Figs.  259-264  inclu- 
sive).— This  is  usually  caused  by  direct  violence.  The  fracture 
occurring  at  any  part  of  the  shaft  presents  no  unusual  symptoms. 
The  head  of  the  bone  does  not  rotate  with  the  shaft  unless  the 
fragments  are  locked.   Abnormal  mobility,  pain,  and  crepitus  are 


Radial  head. 


Radial  shaft. 


Greater  sigmoid  cavity 
of  the  ulna. 


Ulna  shaft. 


Fig.  250.— Common  displacement  in  fracture  of  the  neck  of  the  radius  (after  Mouchet). 


present.  The  displacements  van.-  with  the  situation  of  the  frac- 
ture. Pronation  and  supination  will  be  limited  and  painful.  This 
fracture  has  been  mistaken  for  a  subluxation  of  the  radial  head. 
A  fracture  of  the  radial  shaft  at  the  junction  of  the  lower  and 
middle  thirds  will  sometimes  suggest  ver\-  plainly  the  lateral  de- 
formit}-  in  a  Colles'  fracture,  the  prominent  ulna  and  apparentlv 
shortened  styloid  process  of  the  radius  being  in  evidence.  If  the 
fracture  occurs  in  the  upper  third  of  the  bone,  the  displacement 
of  the  upper  fragment  will  be  considerable. 

Separation  of  the  Lower  Epiphysis  of  the  Radius  (see  Figs. 


'/////, 


Fig.  251. — Fracture  of  both  bones  of  the 
forearm  at  the  middle,  showing  falling  to- 
gether of  broken  ends  (X-ray  tracing). 


Fig.  252. — Fracture  of  both  bones  of  the 
forearm,  showing  differences  in  level  and 
that  the  seat  of  fracture  is  in  the  lower 
third  of  bones. 


Fig.  253.— Fracture  of  radius  alone.  Slight  lateral,  considerable  anteroposterior,  dis- 
placement. The  fallacy  of  depending  upon  an  X-ray  taken  in  one  plane  only  is  here  illus- 
trated (X-ray  tracing). 

196 


FRACTURES  OF  BOTH  RADIUS  AND  ULNA         1 97 

265,  266). — The  lower  radial  epiphysis  unites  to  the  shaft  of  the 
bone  at  the  twentieth  year.  Previous  to  this  age  a  separation 
of  the  epiphysis  is  not  at  all  uncommon.  Many  cases  of  separa- 
tion of  this  epiphysis  are  thought  to  be  Colics'  fractures,  and  they 
are  treated  as  such.  The  treatment  of  a  Colles'  fracture  may  pre- 
sent considerable  difficulties.  Ordinarily  the  treatment  of  a 
separation  of  this  epiphysis  is  simple.  There  is  little  difficulty  in 
maintaining  the  fragments  in  position  in  separation  of  the  epi- 
physis. The  epiphyseal  separation  requires  a  short  time  in  splints. 
A  soft,  cartilaginous  crepitus  is  felt.  There  are  usually  less 
swelling  and  less  pain  than  in  a  Colles'  fracture.     The  deformity 


Fig.  254.— Manner  of  grasping  forearm  to  detect  the  presence  of  fracture.     Xoie  the  firmness 

of  grasp. 


is  quite  constant :  a  prominence  near  the  carpus  on  the  dorsum  of 
the  wrist  and  a  prominence  higher  up  on  the  palmar  surface  of 
the  wrist.  There  is  almost  no  tendency  to  reproduction  of  the 
deformity  after  it  is  once  reduced. 

Fracture  of  the  shaft  of  the  ulna  occurs  usually  because  of  a 
direct  blow  received  upon  the  arm  raised  for  protection.  It  is 
more  uncommon  than  fracture  of  the  radius  (see  Figs.  268, 
269). 

Localized  tenderness,  pain  upon  attempting  to  use  the  forearm, 
obscure  discomfort  in  the  arm  after  an  injur\- — these  may  be 
the  only  signs  of  fracture.  There  is  no  general  swelling  of  the 
forearm.     Ordinarily,  there  will  be  very  little  displacement,  be- 


198       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

cause  the  radius  serves  as  a  splint  for  the  broken  bone.  Crepitus 
may  be  detected  if  the  ulna  is  grasped  between  the  fingers,  placed 
either  side  of  the  fracture,  and  motion  is  attempted.  The  shaft  of 
the  ulna  being  subcutaneous  throughout  its  entire  extent,  the 
tender  seat  of  fracture  can  be  easily  determined  (see  Fig.  270). 


'V'-&^-' 


Fig.  255.  —  Green- 
stick  fracture  of  botii 
bones  of  the  forearm 
(diagram). 


Fig.  256. — Greeiistick  frac- 
ture of  botli  bones  of  the  fore- 
arm. Notice  characteristic  de- 
formity (X-ray  tracing). 


Fig.  257. — Complete  frac- 
ture of  uhia  and  greenstick 
fracture  of  radius  (X-ray  trac- 
ing). 


Fracture  of  the  coronoid  process  of  the  ulna  is  associated 
with  backward  dislocation  of  the  ulna.  It  is  a  rare  accident.  A 
very  small  fragment  is  broken  off,  and  it  is  not  much  displaced. 
If  in  any  dislocation  of  the  forearm  backward  recurrence  of  the 
deformity  after  reduction  occurs  readily,  a  fracture  of  the  coro- 


Fig.  258.— Right  fore- 
arm bones  in  semipronatioii 
from  front  and  inner  side, 
showing  epiphyses;  child  of 
eight  years  (Warren  Mu- 
seum, specimen  334). 


Fig.  259. — Fracture  of  radius. 
Slight  lateral  displacement.  See 
figure  260  (X-ray  tracing). 


Fig.  260. — Fracture 
of  radius.  Slight  an- 
teroposterior displace- 
ment (same  as  Fig.  259, 
X-ray  tracing). 


Fig.  261.— Comminuted  fracture  of  ra- 
dius, low  down,  and  of  ulnar  styloid  (.X-ray 
tracing). 


Fig.  262.— To  illustrate  so  great  damage 
to  lower  end  of  radius  that  complete  restor- 
ation to  normal  is  impossible  (X-ray  trac- 
ing). 


199 


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A  aci; 

D.e 


2;  M 


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200 


TREATMENT 


20 1 


noid  should  be  suspected.  This  will  be  confirmed  by  the  dis- 
covery of  a  small  hard  mass  in  front  of  the  elbow- joint  just  above 
the  insertion  of  the  brachialis  anticus  muscle;  roughly,  a  finger- 
breadth  above  the  bend  of  the  elbow.  This  small  hard  mass  may 
give  crepitus  upon  being  manipulated.  It  is  very  difficult  to  detect 
this  fragment  of  the  coronoid  process  even  under  the  most  favora- 
ble conditions.     The  Rontgen  ray  may  discover  it. 

Treatment  of  Fractures  of  the  Forearm. — The  objects  of 


;05rV5 


Fig.  265. — Oblique  fracture  of  the  shaft  of 
the  radius. 


Fig.  266. — Separation  of  the  lower  epiphy- 
sis of  the  radius  without  displacement. 


treatment  are  to  prevent  permanent  deformity  and  to  preserve 
the  movements  of  pronation  and  supination. 

Fractures  of  Both  Radius  and  Ulna. — All  fractures  of  the  fore- 
arm attended  with  overriding  or  angular  displacement  that  do 
not  yield  readily  to  traction,  countertraction,  and  pressure  should 
be  reduced  under  complete  anesthesia.  While  an  assistant  makes 
countertraction  upon  the  upper  part  of  the  forearm  the  surgeon, 
holding  the  low^er  end  of  the  limb,  makes  strong,  even  traction, 
at  the  same  time  pressing  the  bones  into  position.  \\'hen  the 
angular  deformity  is  corrected,  the  forearm  should  be  strongly 
supinated.  This  supination  will  assist  in  preventing  the  bones 
becoming  locked  close  together  (see  Fig.  273). 


202 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


In  order  to  immobilize  a  fracture  of  the  shaft  of  a  bone  not  only 
must  the  fracture  itself  be  held  firmly,  but  the  joint  immediately 
above  and  below  the  seat  of  fracture  must  be  immovably  fixed. 
If  the  arm  is  seen  immediately  after  the  accident,  and  the  soft 
parts  are  not  evidently  bruised,  and  there  is  little  swelling,  a 
plaster-of- Paris  splint  should  be  applied.  It  should  extend  from 
the  axilla  above  to  the  metacarpophalangeal  joints  below.  The 
arm  should  be  flexed  to  a  right  angle  and  the  forearm  semi- 
supinated  (thumb  upward)    (see  Fig.  274). 


Fig.  267. — Old  fracture  of  both  bones 
of  the  forearm  ;  pseudoarthrosis  of  ulna. 
Radial  fracture  has  united  (X-ray  tracing). 


Fig.  26S. — Fracture  of  the  shaft  of  the 
ulna.  Slight  lateral  displacement.  Local- 
ized tenderness  clinically  the  only  symp- 
tom (Massachusetts  General  Hospital,  1036. 
X-ray  tracing). 


Precautions  in  Using  the  Plaster-of- Paris  Splint:  The  forearm 
should  be  held  in  the  corrected  position  by  an  assistant  through- 
out the  application  of  the  plaster  bandages.  Two  assistants  will 
facilitate  the  putting  on  of  the  plaster.  The  forearm  and  upper 
arm  should  be  thinly  covered  with  one  layer  of  sheet  wadding; 
cotton  wadding  should  not  be  used.  No  salt  should  be  used  in 
the  water  in  which  the  plaster  bandages  are  dipped.  It  will 
require  about  three  or  four  bandages,  three  inches  wide  and  four 
yards  long,  for  an  ordinary  muscular  adult  arm.     The  plaster 


TREATMENT 


203 


roller  slioiikl  be  applied  deliheralely,  evenly,  and  snugly  from  Ihe 
metacarpophalangeal  joints  to  the  axilla.  Great  lateral  com- 
pression of  the  arm  will  be  avoided  if  the  bandage  is  applied  as 
directed.  There  will  be  insuflicient  compression  to  crowd  the 
bones  together  and  so  produce  deformity. 

After-care  of  the  Plaster  vSplints:  When  the  plaster  has  set 
iirmlv,  the  assistant  may  place  the  forearm  in  a  sling  of  comfort- 
able height  to  support  the  arm.  Inspection  of  the  fingers  will  de- 
termine the  condition  of  the  circulation  in  the  limb.  If  there  is 
too  great  pressure,  if  the  splint  is  too  tight,  a  blueness  will  appear, 


Fig.  269. — Fracture  of  ulna,  low  down, 
with  considerable  lateral  displacement  and 
shortening  of  shaft  (X-ray  tracing.  Massa- 
chusetts General  Hospital,  5693). 


Fig.  270.— Partial  fracture  of  ulna.  T- 
shaped  line  of  the  fracture  (Warren  Mu- 
seum, 3722). 


indicating  a  sluggishness  in  the  circulation.  If  this  sign  appears, 
the  splint  should  immediately  be  split  from  axilla  to  hand  by  a 
knife.  This  wall  relieve  the  circulation.  Ordinarily,  there  is  no 
difficulty  of  this  sort.  The  patient  should  be  seen  each  day  for 
the  first  week  after  the  dressing  is  put  on.  Inquiry  should  be 
made  for  pain  and  throbbing  in  the  arm  and  sleeplessness,  which 
are  evidences  of  too  great  pressure.  If  the  arm  is  doing  well, 
the  splint  should  cause  no  discomfort.  After  one  week  the  plaster 
splint  should  be  removed,  for  the  swelling  of  the  arm  will  have 
diminished  and  the  splint  will  have  become  loosened.     Unless 


204 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


this  loosening  is  corrected,  an  opportunity  for  deformity  to  occur 
will  then  exist.  Either  a  new  plaster  should  be  applied  or  the 
old  splint,  if  suitable,  should  be  reapplied  and  tightened  by  a 
bandage.  If  the  splint  is  too  large,  it  may  be  made  smaller  by 
removing  a  strip  of  plaster  the  entire  length  of  the  splint.  The 
edges  of  the  cut  plaster  should  be  bound  with  strips  of  adhesive 


Ulna.        Radius. 

Fig.  271.— Sliowing  dis- 
tance between  bones  and 
their  relation  to  mass  of 
soft  parts.  Median  section 
of  forearm  (from  frozen  sec- 
tion by  Dwight). 


Fig.  272. — Variations  in  the  shape  and  width  of  the  in- 
terosseous space  between  radius  and  ulna  when  the  fore- 
arm is  supinated,  pronated,  and  semipronated.  Semi- 
pronation  presents  the  widest  interosseous  space  (dia- 
gram). 


plaster  to  prevent  chafing  of  the  skin  and  crumbling  of  the  plaster. 
The  position  of  the  bones  at  the  seat  of  fracture  should  be  noted. 
The  degree  of  movement  possible  at  the  seat  of  fracture  should 
be  noted.  At  the  end  of  each  week  the  splints  should  be  removed. 
After  about  three  weeks,  when  union  is  well  advanced,  the  plaster 
splint  may  be  cut  off  below  the  elbow  and  the  upper  part  dis- 


TREATMENT 


205 


carded,  or  a  posterior  splint  of  wood  may  be  applied  for  lightness 
and  convenience. 

If  the  force  was  a  direct  violence  and  there  is  injur}'  to  the  soft 
parts,  if  the  swelling  is  considerable  and  is  likely  to  be  greater,  it 
will  be  best  to  use  palmar  and  dorsal  splints  of  wood  upon  the  fore- 


Fig.  273. — Fracture  of  the  forearm  low  down,  or  Colles'  fracture.    Anterior  and  posterior 
splints,  three  straps,  radial  pad.    Anterior  splint  cut  out  to  fit  thenar  eminence. 


Fig.  274. — Fracture  of  the  forearm.     Manner  of  holding  arm  and  of  applying  the  adhesive- 
plaster  straps.     Posterior  splint  of  splint  wood. 


arm  and  an  internal  right-angle  splint  at  the  elbow.  The  fore- 
arm is  held  in  the  position  of  semisupination.  The  maximum 
swelling  occurs  within  the  first  forty-eight  hours — barring,  of 
course,  inflammatory  disturbances,  which  are  not  to  be  considered 
here.     The  splints  should  be  of  thin  splint  wood,  which  is  stiff 


2o6 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


enough  not  to  yield  to  ordinary  pressure.  In  width  they  should 
be  one-fourth  of  an  inch  wider  than  the  forearm.  The  posterior 
splint  should  extend  from  just  above  the  middle  of  the  forearm 
to  the  metacarpophalangeal  joints.  The  anterior  splint  should 
extend  from  the  same  point  on  the  forearm  to  the  middle  of  the 
palm  of  the  hand  (see  Fig.  273).  The  palmar  splint  is  cut  out  on 
the  thumb  side,  so  as  to  avoid  pressure  on  the  thenar  eminence. 
These  two  splints  are  padded  with  evenly  folded  sheet  wadding 


Fig.  275. — Fracture  of  both  bones  of  the  forearm.     Proper  position  of  arm  in  sling.     Note  hand 
is  unsupported  by  sling,  and  arm  rests  on  ulnar  side.     Notice  height  of  arm. 


no  wider  than  the  splints.  About  three  or  four  thicknesses  of 
the  sheet  wadding  will  be  necessary.  The  posterior  splint  is 
padded  alike  through  its  whole  extent.  The  anterior  splint  is  so 
padded  as  to  conform  to  the  irregularities  of  the  anterior  surface 
of  the  forearm,  particularly  at  the  radial  side  near  the  wrist.  The 
internal  right-angle  splint  is  padded  evenly  with  four  thicknesses 
of  sheet  wadding.  It  overlaps  the  wooden  splints,  and  extends 
up  to  the  axilla.     It  immobilizes  the  elbow-joint. 

The  Application  of  the  Splints:  The  forearm  is  held  flexed  at 


TREATMENT 


207 


a  right  angle  and  semisupinated  and  steadied  by  an  assistant. 
The  posterior  and  then  the  anterior  splints  are  applied  to  the 
forearm.  Three  straps  of  adhesive  plaster,  two  inches  broad,  are 
then  applied — one  at  the  upper  ends  of  the  splints,  one  at  the 
wrist,  and  the  third  across  the  palm  of  the  hand  and  around  the 
posterior  splint  only.  These  straps  should  simply  steady  the 
splints  snugly  in  position  (see  Fig.  274).  The  bandage  is  next 
applied,  and  it  is  by  this  that  pressure  is  exerted  upon  the  arm. 
There  should  be  some  spring  left  upon  pressing  the  splints  together 
after  the  bandage  is  applied.     If  there  is  none  remaining,   too 


Fig.  276. — Fracture  of  bolh  boties  of  the  forearm.  Ulnar  view  of  the  anterior  and  posterior 
splints.  Note  length  of  splints  and  position  of  straps.  Straps  of  the  internal  right-angle  splint, 
3  and  4. 


great  pressure  will  be  made  on  the  arm  and  the  circulation  will 
be  interfered  with.  The  arm  is  placed  in  a  sling  of  comfortable 
height  (see  Fig.  275). 

If  the  fracture  of  the  forearm  is  above  the  middle  of  the  bones, 
the  tin  internal  right-angle  splint  should  be  used  to  immobilize  the 
elbow- joint.  This  should  be  applied  after  the  wooden  splints 
are  in  place  and  v>-hile  the  arm  is  semisupinated.  A  bandage  is 
then  placed  over  both  wooden  and  tin  splints  (see  Figs.  276,  277, 
278). 

After-care  of  Wooden  and  Tin  Splints:  The  patient  should  be 


2o8      FRACTURES  OF*  THE  BONES  OP  THE  FOREARM 

seen  every  day  for  two  or  three  days  after  the  fracture.  The 
splints  should  be  readjusted  and  applied  more  snugly  by  a  fresh 
bandage.  The  comfort  of  the  patient  should  be  considered;  any 
complaint  on  the  part  of  a  sensible  individual  should  be  inquired 
into.  If  the  apparatus  is  applied  with  the  bones  in  approximately 
normal  position,  there  should  be  no  subsequent  discomfort.  All 
splints  should  be  removed  at  least  twice  a  week  throughout  active 
treatment,  and  the  presence  of  deformity  noted  and  corrected. 
After  the  first  week  or  week  and  a  half,  the  swelling  having  sub- 


Fig.  277. — Fracture  of  the  bones  of  forearm.  Forearm  supinated.  Anterior  and  posterior 
splints  and  tin  interna!  angular  splints,  i  and  2,  Straps  holding  anterior  and  posterior  splints  ; 
3,  4,  and  5,  straps  holding  internal  right-angle  splint. 


sided,  it  is  often  advantageous  to  apply  in  place  of  these  splints 
of  wood  the  plaster-of- Paris  splint,  which  has  been  described  (see 
p.  202). 

Fracture  of  the  head  and  neck  of  the  radius  and  fracture  of  the 
coronoid  process  of  the  ulna  should  be  treated  by  the  internal  right- 
angle  splint  with  the  forearm  semipronated — that  is,  with  the 
thumb  up  (see  Fig.  278). 

Fracture  of  the  shaft  of  the  radius,  if  above  the  middle  of  the  bone, 
should  be  treated  by  the  anterior  and  posterior  wooden  splints  and 


TREATMENT 


209 


the  internal  right-angle  splint.  If  below  the  middle  of  the  bone, 
the  internal  right-angle  splint  may  be  omitted,  although  it  may 
be  well  to  retain  it  in  most  instances.  If  the  fracture  is  in  the 
upper  third  of  the  bone,  it  may  be  impossible  to  correct  the  de- 
formity without  making  an  open  fracture  and  suturing  the  frag- 
ments together.  It  may  be  possible  to  approximate  the  fragments 
by  putting  the  forearm  in  a  position  of  semipronation.  No  special 
splint  is  necessary  to  mJiintain  this  position ;  the  two  wooden  ante- 
rior and  posterior  splints  and  the  tin  internal  right-angle  splint 
fulfil  all  the  indications. 

Separation  of  the  lower  radial  epiphysis  is  treated  h\  anterior  and 


Fig.  278.— Fracture  of  both  bones  of  the  forearm.  Anterior  and  posterior  splints  and  tin 
internal  right-angle  splint  immobilizing  elbow-joint.  Note  arm  in  semipronation,  "thumb 
up  "  ;  position  of  straps  ;  padding  of  internal  right-angle  splint. 


posterior  splints,  similarly  to  the  treatment  of  a  Colles'  fracture 
(see  Fig.  273). 

Fracture  of  the  shaft  of  the  iilna  should  be  treated  as  fractures  of 
the  shaft  of  the  radius  are  treated. 

How  long  should  splints  be  kept  on  in  fractures  of  the  forearm? 
Until  union  is  firm  enough  between  the  fragments,  so  that  firm 
pressure  does  not  cause  motion.  ^A'hen  the  fracture  is  firm,  ordi- 
narily after  about  three  weeks  and  a  half,  the  anterior  and  internal 
angular  splints  may  be  omitted,  the  posterior  splint  alone  being 
left  in  place.  If  the  posterior  splint  of  wood  is  used,  a  broad  (four- 
inch)  strap  of  adhesive  plaster,  in  addition  to  the  two  ordinary 
14 


210 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


Straps  at  each  end  of  the  sphnt,  should  be  placed  at  the  seat  of 
fracture  and  a  gauze  bandage  applied  over  all.  At  the  end  of  the 
fourth  or  fifth  week  all  splints  should  be  omitted.  Continual 
watchfulness  is  demanded  in  order  that  bowing  at  the  seat  of  frac- 
ture may  not  take  place.  The  application  of  the  sling  after  the 
omission  of  splints  should  be  carefully  made  to  avoid  backward 


Fig.  279. — Application  of  sling.  Proper  position  of  triangular  bandage  in  first  step.  2  is 
carried  over  right  shoulder;  i  drops  over  left  shoulder;  i  and  2  are  fastened  behind  the  neck  ; 
3  is  brought  forward  and  pinned,  as  shown  in  figure  280. 


bowing  of  the  bones.  A  laboring  man  should  not  go  to  work  for 
at  least  from  four  to  six  weeks  after  leaving  off  splints.  A  return 
to  work  too  early  causes  bowing  of  the  fracture  and  pain  in  the 
arm. 

Massage  and  passive  motion  should  be  employed  as  soon  as 
union  is  firm  and  the  anterior  and  internal  angular  splints  have 
been  removed.     Massage  may  be  given  at  first  without  removing 


PROGNOSIS    AND    RESULT    OF    TREATMENT  211 

the  arm  from  the  splint.     Convalescence  will  proceed  more  rap- 
idly in  consequence  of  massage. 

When  will  the  arm  be  restored  to  normal  usefulness?  It  is  im- 
possible to  answer  this  question  accurately.  The  conditions  in 
each  individual  instance  of  fracture  are  so  variable  that  no  gen- 
eral statement  can  be  made  that  will  more  than  indicate  the 
probable  time  of  convalescence.  It  may  be  fairly  stated  that  in 
an  uncomplicated  fracture  of  both  bones  of  the  forearm  the  arm 


Fig.  2S0. — Application  of  sling.     Final  position  of  arm.     Two  ends  tied  behind  neck  and  the 

third  end  pinned. 


will  be  useful  for  working  in  from  two  to  three  months  from  the 
time  of  fracture. 

The  treatment  of  open  fractures  of  the  forearm  is  best  con- 
ducted by  methods  described  under  open  fractures  of  the  leg: 
briefly,  absolute  cleanliness,  suturing  of  bones,  sterile  dressing, 
immobilization  of  the  part. 

Prognosis  and  Result  of  Treatment. — There  may  be  some 
limitation  of  supination   and   pronation   immediately   after  the 


212 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


splints  are  removed.  As  the  callus  diminishes  and  with  persist- 
ent movements  of  the  arm  in  ordinary  use  this  limitation  should 
diminish,  and  in  some  instances  entirely  disappear.  If  the  frac- 
ture is  in  the  upper  or  lower  thirds  of  the  bones,  the  limitation 
of  motion  will  often  be  greater  than  when  the  fracture  is  at  the 
middle  of  the  bones.  The  interosseous  space  is  greatest  at  the 
middle  of  the  shafts  (see  Fig.  272);  consequently,  callus  at  this 
point  is  less  likely  to  impair  motion  of  the  forearm.     The  arm 


Fig.  281. — Compound  fracture  and  dislocation  at  tiie  wrist.     Hand  saved. 


should  be  straight.     Movements  of  the  wrist  and  elbow  should 
be  perfectly  normal. 

Nonunion  of  Fractures. — If  after  the  usual  time  has  elapsed  for 
a  fracture  to  have  united  firmly  it  has  failed  of  union,  delayed 
union  is  said  to  exist.  If  after  a  longer  time  no  union  occurs, 
nonunion  is  said  to  exist.  A  case  of  delayed  union  may  result 
in  nonunion  or  it  may  become  united.  The  term  nonunion  does 
not,  however,  necessarily  imply  that  no  union  exists  between  the 
bones,  but  simply  that  bony  union  does  not  exist.  In  cases  of  so- 
called  nonunion  fibrous  union  is  often  present.  The  causes  of  non- 
union are  local  and  general.     Of  the  local  causes  the  commonest 


PROGNOSIS    AND    RESULT    OF    TRI-ATMENT 


213 


is  the  interposition  of  some  soft  tissue,  such  as  torn  periosteum, 
strips  of  fascia  or  muscle,  between  the  fragments.  A  wide  separa- 
tion and  imperfect  immobilization  of  the  fragments  are  also  factors 
in  the  occurrence  of  nonunion.  Of  the  general  causes  it  is  thought 
that  syphilis,  pregnancy,  prolonged  lactation,  the  wasting  dis- 
eases, rachitis,  and  the  acute  febrile  diseases  may  contribute  some- 
thing toward  nonunion. 

The  constitutional  treatment  of  nonunion  is  of  primary  impor- 
tance, together  with  reduction  and  absolute  immobilization  of  the 
fragments.     If  these  measures  fail  after  a  fair  trial,  a  rubbing  of 


Fig.  282. — Method  of  applying  force  in  completing  a  greenstick  fracture  of  the  forearm.     The 
force  is  applied  in  the  direction  of  the  original  force  (diagram). 


the  ends  of  the  fractured  bones  together  and  then  immobilizing 
them  is  sometimes  effective.  If  this  fails  too,  operative  meas- 
ures should  be  instituted  for  making  the  fracture  an  open  one  for 
the  removal  of  any  interposed  tissues.  Careful  fixation  will, 
after  such  operative  procedure,  usually  effect  union.  If  for  some 
unremediable  constitutional  reason  union  does  not  result  after 
operation,  a  splint  should  be  devised  to  make  the  damaged  part 
as  useful  as  is  compatible  with  nonunion. 

Treatment  of  Greenstick  or  Incomplete  Fracture  of  the  Bones  of  the 
Forearm. — It  is  impossible  to  maintain  the  correction  of  the  de- 
formity if  the  bones  are  sim.ply  bent  back  into  position.     Even 


214       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

with  the  greatest  care  in  the  use  of  pads  and  pressure  the  deform- 
ity will  in  part  reappear.  It  is  necessary,  therefore,  to  administer 
an  anesthetic,  and  to  make  a  complete  fracture  of  the  greenstick 
fracture.  This  done,  the  arm  is  set  as  in  a  complete  fracture. 
The  best  method  of  refracturing  the  greenstick  fracture  is  to  bend 
the  arm  with  the  two  hands  in  the  direction  of  the  original  force 
(see  Fig.  282). 

The  anterior  and  posterior  wooden  splints  may  be  used  with 
satisfaction.  Ordinarily,  the  plaster-of-Paris  splint  as  applied 
in  complete  fractures  is  the  best  apparatus.  Union  in  children 
after  fracture  is  more  rapid  than  in  adults.  At  the  end  of  two 
weeks  union  will  be  found  firm.  It  is  well  not  to  omit  all  apparatus 
in  a  child  until  four  weeks  have  passed.  If  great  caution  is 
needed  on  account  of  an  extremely  active  child,  the  posterior 
wooden  splint  should  be  kept  on  during  the  fifth  week. 


FRACTURES  OF  THE  OLECRANON 
The  normal  anatomical  relations  of  the  olecranon  should  be 
kept  constantly  in  mind.  The  insertion  of  the  brachialis  anticus 
muscle  is  into  the  front  and  lower  part  or  base  of  the  coronoid 
process  of  the  ulna.  The  insertion  of  the  triceps  muscle  is  into 
the  posterior  part  of  the  upper  surface  of  the  olecranon  and  into 
the  fascia  of  the  posterior  surface  of  the  forearm.  The  small 
epiphysis  of  the  olecranon  unites  to  the  shaft  about  the  sixteenth 
year.  A  direct  blow  upon  the  olecranon  together  wdth  violent 
muscular  contraction  of  the  triceps  will  produce  the  fracture.  The 
fracture  is  usually  transverse.  A  complete  transverse  fracture  of 
the  olecranon  always  opens  the  elbow- joint  (see  Fig.  283).  Some 
of  the  varieties  of  fracture  of  the  olecranon  are  seen  in  the  accom- 
panying tracings  of  Rontgen-ray  plates  (see  Figs.  284,  285,  286, 
287). 

Symptoms. — Inability  forcibly  to  extend  the  forearm,  pain  at 
the  seat  of  fracture,  and  deformity,  provided  the  fragment  is 
separated  from  the  shaft  of  the  ulna.  A  depression  marks  the 
separation.  Very  great  separation  of  the  fragment  is  not  often 
present.  The  interval  between  the  fragments  depends  upon  three 
conditions:  The  extent  of  the  facial  laceration — if  the  laceration 


FRACTURES  OF  THE  OLECRANON 


215 


is  moderate  in  extent,  the  interval  between  the  fragments  will  be 
slight;  if  the  laceration  is  extensive,   the  interval  between  the 


Fig.  283.— Showing  relations  of  olecranon  to  elbow-joint ;  practically  all  fractures  are  intra- 
articular. 


Seat  of  fracture. 

Fig.  284.— Splintered  fracture  of  olecranon  without  much  displacement  (Massachusetts  Gen- 
eral Hospital,  1536.     X-ray  tracing). 


fragments  may  be  great ;  the  position  of  the  arm,  whether  flexed 
or  extended— if  flexed,  the  separation  will  be  greater  than  if  ex- 
tended (see  Fig.  288);  the  amount  of  synovial  fluid  and  blood  in 


2l6 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


the  joint — the  greater  the  amount  of  fluid,  the  greater  will  be  the 
separation  of  the  fragments.     The  mobility  of  the  fragments  of 


Radius. 


Coronoid  process. 


Ulnar  shaft. 


Olecranon. 


Seat  of  fracture. 


Fig.  285. — Fracture  of  olecranon.     No  displacement  detected  clinically.     No  symptoms  other 
than  local  tenderness  and  slight  swelling  (X-ray  tracing). 


Olecranon. 


Ulnar  shaft. 
Fig.  286.— Fracture  of  olecranon;  separation  of  fragments  upon  flexing  forearm  (X-ray 

tracing). 


the  olecranon  is  determined  by  grasping  the  olecranon  firmly  and 
attempting  lateral  motion   (see  Fig.    207).     Crepitus  may  thus 


TREATMENT 


217 


be  elicited.  The  general  swelling  about  the  elbow  will  be  con- 
siderable if  the  traumatism  was  severe.  There  exists  a  traumatic 
synovitis  of  the  elbow-joint. 


Line  of  fracture. 
Fig.  287. — Fracture  of  olecranon  at  about  the  epiphyseal  line,  without  opening  the  elbow-joint 
(Massachusetts  General  Hospital,  1172.    X-ray  tracing). 


Fig.  288. — Diagrams  to  illustrate  separation  of  fragment  of  olecranon  by  the  triceps  and  in 
flexion  of  the  elbow. 


Treatment. — If  there  is  considerable  swelling  of  the  elbow,  and 
if  the  arm  is  large  and  muscular,  it  is  wise  to  rest  the  arm  for  a 


2l8       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

few  days  (at  least  five  or  six)  upon  an  internal  right-angle  splint 
before  putting  it  up  permanently.  The  swelling  will  disappear 
in  the  mean  time,  and  a  more  accurate  examination  of  the  arm 
can  then  be  made.  If  there  is  little  or  no  separation  of  the  frag- 
ments in  the  right-angle  position,  the  arm  may  be  kept  at  a  right 
angle.     This  is   doubtless  the  most  comfortable  position,   and. 


^^^■:.  ■^"^■'U^SMS^^^^^M 

^g               J. 

p* 

^^^^KF^^\Y7^^^Kfr 

f 

^r^              .Jt^K^^^^^^^^k 

' 

^1  ■•  i^SS^^^^B 

L^^^ 

I^H 

-^^^^^1 

^1 

Fig.  2S9.— Fracture  of  the  olecranon.     Arm  in  extension.     Long  anterior  splint.     Note  pad 
and  strap  above  olecranon  fragment ;  pad  in  palm  of  hand. 


under  these  conditions,  certainly  is  effective.  If  there  is  marked 
separation  (half  an  inch  or  more),  the  arm  should  be  extended 
and  this  position  maintained  by  a  long  internal  splint  (see  Fig. 
289).  This  splint,  made  of  splint- wood,  should  be  the  width  of 
the  arm,  and  should  reach  from  the  anterior  axillary  margin  to 
the  tips  of  the  fingers.  This  is  well  padded  with  sheet  wadding  at 
the  bend  of  the  elbow  (see  Fig.  290).     The  contiguous  skin  sur- 


TREATMENT 


2  19 


faces  of  the  fingers  are  protected  from  chafing  by  strips  of  gauze  or 
compress  cloth  placed  between  them,  and  a  pad  is  put  in  the  palm 
for  comfort  (see  Fig.  291).  The  splint  is  held  in  position  by  four 
straps  of  adhesi\e  plaster,  one  placed  at  either  end  of  the  splint  and 
one  above  and  below  the  elbow-joint.  The  upper  or  loose  frag- 
ment is  pushed  down  toward  the  shaft  of  the  ulna,  and  held  in 


Fig.  290.— Fracture  of  olecranon.     Arm  in  extension.     Note  upper  and  lower  straps  ;  oblique 
olecranon  strap  ;  padding  of  splint. 


place  by  a  strap  of  adhesive  plaster  carried  around  the  upper  side 
of  the  olecranon  fragment  and  fastened  to  the  splint  lower  down. 
Sheet  wadding  and  gauze  roller  bandages  applied  from  the  fingers 
to  the  axilla  afford  comfort  and  prevent  undue  swelling  of  the 
hand.  >Should  the  separation  be  so  great  that  reduction  of  the 
fragment  is  unsatisfactory,  an  incision  and  suture  should  be  made 
(see  Fig.  291). 


2  20       FRACTURES  OF  THEI  BONES  OF  THE  FOREARM 

Treatment  if  the  Fracture  is  Open. — The  wound  should,  if  nec- 
essary, be  enlarged  to  permit  of  easy  inspection  of  the  joint  surface. 
The  joint  should  be  thoroughly  irrigated  with  boiled  water.  The 
wound  of  the  soft  parts  should  be  very  thoroughly  cleansed  by 
scrubbing  with  gauze  wet  in  corrosive  sublimate  solution,  i  :  5000, 
and  then  the  fragment  of  the  olecranon  sutured  to  the  shaft. 


Fig.  291. — Fracture  of  olecranon.     Bandage  applied  to  the  same  case  as  shown  in  figures  2S 
290.     Note  protection  of  fingers  from  chafing  by  compress  cloth  and  bandaging  of  hand. 


The  After-care. — If  the  arm  has  been  put  up  temporarily  at  a 
right  angle  to  await  the  subsidence  of  the  swelling,  gentle  massage 
and  firm  bandaging  of  the  arm,  twice  daily,  until  the  swelling  sub- 
sides sufficiently  for  accurate  examination  and  a  more  perma- 
nent dressing,  will  be  of  very  great  service.  The  arm  should  be 
inspected  each  day  for  the  first  week.  Daily  massage  should  be 
continued  not  only  to  the  joint  region,  but  to  the  forearm  and 


TREATMENT 


221 


Upper  arm  as  well.  The  straps  and  bandages  should  be  reapplied 
as  they  become  too  tight  or  are  loosened  by  the  disappearance  of 
the  swelling.  After  about  two  weeks  the  position  of  the  forearm 
may  be  cautiously  changed.  The  small  fragment  of  the  olecranon 
should  be  held  fixed  during  the  manipulation.  If  the  arm  is  in 
the  extended  position,  it  should  be  gradually  flexed  some  five  or 
ten  degrees,  and  returned  to  the  extended  position.  If  the  arm  is 
already  at  a  right  angle,  it  should  be  gradually  extended,  at  first  a 


Fig.  292.— Method  of  examination  of 
wrist.  Note  supination  of  forearm  ;  posi- 
tion of  examining  hands  and  iingers  ;  pal- 
pation of  the  styloid  process  of  the  radius 
and  the  head  of  the  ulna.  The  radial  sty- 
loid is  seen  to  be  lower  than  the  head  of 
the  ulna. 


Fig.  293. — Method  of  examination  of 
wrist.  Note  pronation  ot  forearm  ;  posi- 
tion of  examining  hands  and  fingers;  pal- 
pation of  styloid  processes  of  radius  and 
ulna.  The  styloid  of  the  radius  is  lower 
than  the  styloid  of  the  ulna. 


few  degrees  only,  and  returned  to  the  right-angle  position.  Xo 
pain  should  be  experienced  by  the  passive  motion.  Painful 
passive  motion  is  harmful.  After  a  few  da^'S  of  these  gentle  pas- 
sive motions  it  will  be  wise  to  alter  the  angle  of  the  splint  so  that 
the  arm  may  rest  in  the  changed  position  permanently.  After 
about  four  or  five  weeks  all  splints  should  be  omitted.  A  bandage 
should  be  worn  after  the  removal  of  the  splints  to  afford  support 
to  the  elbow. 


222 


FRACTURES  OF"  THE  BONES  OF  THE  FOREARM 


Union  of  the  fragments  usually  takes  place  in  from  three  to 
four  weeks.  After  six  weeks  to  three  months  the  movements  of 
the  elbow- joint  should  be  normal.  There  may  remain  as  a  per- 
manent condition  slight  limitation  of  extension.  The  functional 
usefulness  of  the  elbow  depends  more  upon  the  approximation 
of  the  fragments  and  less  upon  the  kind  of  union  between  them. 
The  union  between  the  fragments  is  more  often  ligamentous  than 
bony.  The  short  fibrous  union,  if  of  good  width, — i.  e.,  if  it  covers 
the  whole  of  the  broken  surface, — is  as  efficient  as  a  bony  union. 


Fig.  294. — a,  Tip  of  radius  ;  6,  styloid  process  of  ulna ;  c,  ulnar  head.  i.  Supination.  2. 
Pronation.  To  illustrate  that,  in  comparing  the  level  of  the  styloid  of  radius  with  lower  end 
of  ulna,  as  in  figures  292,  293,  in  supination,  i,  the  head  of  the  ulna  is  felt,  and  that  in  prona- 
tion, 2,  the  styloid  of  the  ulna  is  felt. 


A  ligamentous  union  accompanied  by  great  disability  in  the  func- 
tional usefulness  of  the  arm  should  be  excised  and  the  bony  frag- 
ment sutured  to  the  shaft.  Suturing  of  the  periosteum  and  fibrous 
tissue  about  the  fragments  will  prove  fully  as  satisfactory  in  many 
cases  as  suturing  the  bone  with  silver  wire. 

Summary:  If  there  is  great  swelling,  delay  the  application  of 
the  permanent  splint.  Apply  internal  right-angle  splint.  Use 
compression  and  massage.  If  there  is  little  or  no  separation  of 
the  fragments,  use  a  right-angle  splint.     If  there  is  marked  sepa- 


COLLES     FRACTURE 


223 


ration  of  fragiiK'Hts,  use  an  fxtfiulcd  ])()sitioii.  If  tlu-  iVaclure  is 
open,  suture  the  fragnienls.  If  practicable,  at  the  outset,  renew 
the  bandage  and  massage  the  arm  twice  daily.  After  two  weeks 
cautious  passive  motion  should  be  made  daily.  After  three  weeks 
the  angle  of  the  splint  should  be  permanently  changed.  After 
four  weeks  all  splints  should  be  removed.  After  six  weeks  to 
three  months  a  useful  arm  should  result. 

TetcDius  is  rarely  seen  after  fracture  of  bone.  It  sometimes 
appears  after  open  fracture.  Early  amputation  and  the  adminis- 
tration of  tetanus  antitoxin  are  the  most  rational  means  of  treat- 
ment in  these  cases. 

COLLES'  FRACTURE 

A  fracture  of  the  lower  end  of  the  radius  within  about  one  inch 
of  the  articular  surface  is  common  in  adults  and  is  unusual  in  child- 
hood. A  fall  upon  the  outstretched  and  extended  hand  is  the 
most  frequent  cause. 

Anatomy. — In  a  case  of  traumatism  to  the  wrist  the  normal 


Fig.  295. — Method  of  examination  in  a  case  of  injury  to  the  lower  end  of  the  radius.     Grasp- 
ing the  radiu.s  above  and  below  the  probable  seat  of  fracture. 


anatomical  relations  should  be  studied  upon  the  uninjured  wrist, 
and  then  a  careful  examination  made  of  the  injury.  The  normal 
wrist  should  be  looked  at  from  the  front  and  back  and  from  each 
side  with  the  hand  supinated.  Anteriorly,  the  base  of  the  thenar 
eminence  is  lower  than  that  of  the  hypothenar  eminence.  Pos- 
teriorly, on  the  inner  side,  the  styloid  process  of  the  ulna  is  visible 
with  the  marked  depression  below  it.     Laterally,  on  the  radial 


224       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

side,  is  seen  the  curve  backward  on  the  anterior  surface  of  the 
radius  where  the  base  of  the  styloid  process  of  the  radius  joins 
the  shaft.  Laterally ,  upon  the  ulnar  side,  are  seen  not  only  the 
styloid  of  the  ulna  and  its  associated  depression,  but  the  hollow 
above  the  prominence  of  the  hypothenar  eminence. 

The  normal  wrist  should  be  felt  with  the  hand  both  in  supina- 
tion and  pronation.  With  the  hand  supinated  (see  Fig.  292)  the 
tip  of  the  styloid  process  of  the  radius  is  found  to  be  lower  (nearer 


Fig.  296. — Diagram  of  fracture   of  base   of  radius  with   anterior  displacement:    "reversed 
CoUes'  fracture"  (term  suggested  by  Roberts). 


Fig.  297.— Colles'  fracture:  the  common  "silver-fork  deformity."     Note  dorsal  and  palmar 
prominences  (diagram). 


the  hand)  than  the  head  of  the  ulna.  With  the  hand  in  pronation 
(see  Fig.  293)  the  tip  of  the  styloid  process  of  the  radius  is  found 
to  be  a  little  lower  (nearer  the  hand)  than  the  tip  of  the  styloid 
process  of  the  ulna.  To  ascertain  the  relative  position  of  the  sty- 
loid processes,  the  injured  wrist  should  be  grasped  by  the  two 
hands  and  the  styloids  felt  by  the  tips  of  the  forefingers.  The 
styloid  process  of  the  radius  and  the  shaft  immediately  above  it 
should  be  carefully  palpated  to  determine  the  extreme  thinness 
of  the  bone  above  the  thick  styloid  process  (see  Fig.  295).     The 


COLLES'    FRACTURU — ANATOMY 


22. 


width  of  the  wrist  between  the  styloid  processes  should  be  meas- 
ured by  means  of  a  tape,  or,  better,  by  a  pair  of  calipers. 

The  movements  of  the  normal  wrist  and  forearm  should  be 
carefully  observed.     Pronation  and  supination  of  the  forearm  and 


Fig.  29S.— CoUes'  fracture.    Characteristic  appearance.     Note  backward  displacement  of  the 
hand  and  wrist.    Palmar  prominence.    Compare  with  figure  297. 


Fig.  293.— Colles'  fracture,  radial  side.     Marked  crease  at  base  of  thumb.     Dorsal  and  palmar 

prominences. 


Fig.  300.— CoUes'  fracture,  ulnar  side.     Absence  of  ulna  on  the  dorsum  of  the  wrist  ;  presence 
anteriorly.    Marked  crease  in  front  of  displaced  ulna.    Dorsal  prominence  marked. 


flexion,  extension,  abduction,  and  adduction  of  the  hand  should 
be  carefullv  performed.  These  simple  observations  quickly  made 
upon  the  normal  wrist  enable  one  to  establish  a  standard  for  com- 
parison wdth  the  injured  wrist.  In  every  case  in  which  there  is  a 
15 


226 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


question  of  fracture  the  examination  should  be  made  by  means 
of  an  anesthetic  (see  Fig.  295).  If  for  sufficient  reason  complete 
anesthesia  is  contraindicated,  primary  anesthesia  will  prove  to 
be  sufficient.  In  the  larger  proportion  of  cases  of  Colles'  fracture 
primary  anesthesia  will  be  satisfactory  for  both  the  examination 
and  the  first  dressing  of  the  fracture. 

Symptoms. — In  Colles'  fracture  the  wrist  appears  unnatural. 
The  thenar  eminence  of  the  thumb  is  higher,  nearer  to  the  wrist 


Fig.  301.  —  Colles' 
fracture,  anterior  bulg- 
ing of  flexor  tendons  ; 
absence  of  dorsal  prom- 
inence of  head  of  ulna. 


Fig.  302. — Colles'  fracture. 
The  dorsal  prominence  is  not 
uncommonly  seen  after  recov- 
ery from  fracture  of  the  radius 
when  the  displaced  bones  have 
been  but  partially  reduced. 
Slight  lateral  deformity. 


Fig.  303.— Colles'  fracture. 
Hand  carried  to  radial  side. 
Prominent  ulna  anteriorly. 
Thenar  eminence  lower  than 
normal. 


than  usual,  as  compared  with  the  hypothenar  eminence  (see  Fig. 
303).  Anteroposterior  and  lateral  deformities  are  apparent  to  a 
greater  or  less  degree.  It  is  said  that  at  times  an  anterior  dis- 
placement of  the  lower  fragment  occurs,  the  reverse  of  the  ordi- 
nary displacement.     It  is  unusual  (see  Fig.  296). 

The  anteroposterior  deformity  is  caused  by  the  projection  of 
the  lower  end  of  the  upper  fragment  into  the  palmar  surface  of  the 
wrist,  pushing  the  flexor  tendons  forward  (see  Fig.  297),  and  by 
the  projection  of  the  upper  end  of  the  lower  fragment  toward  the 


COLLES  FRACTURE — SYMPTOMS 


227 


dorsal  surface  of  the  wrist,  pushing  the  extensor  tendons  back- 
ward. Impaction  of  the  radial  fragments  may  be  another  factor 
in  the  production  of  the  deformity.  This  deformity  is  spoken 
of  by  the  older  writers  as  the  silver-fork  deformity.  The  reason 
is  obvious  (see  Figs.  298,  299,  300,  301,  302). 

The  lateral  deformity  (see  Fig.  303)  is  caused  by  several  factors : 
the  impaction  of  the  radial  fracture,  lateral  displacement  of  the 


Fig.  304.— A  form  of  comminution   in    Colles'  fracture.     Left   wrist   from   back   and   below 

(diagram). 


Line  of  fracture. 

T-line. ,  J , 

Lower  radial  fragment. ZtJiZ-  .^_^ 


Semilunar  bone.  -"^  / 
/ 
/ 


Styloid  process  of  ulna. 


Fig.  305. — Colles'  fracture.     Anteroposterior  view.     Slight  lateral  deformity.     Anterior  view 
of  figure  306  (Massachusetts  General  Hospital,  1028.    X-ray  tracing). 


lower  fragment,  and  by  rupture  of  the  inferior  radio-ulnar  liga- 
ments. The  abduction  of  the  whole  hand,  the  prominence  later- 
ally of  the  lower  end  of  the  ulna,  the  disappearance  of  the  ulnar 
head  from  the  dorsum  of  the  wrist,  are  to  be  noted.  Because  of 
the  displacement  of  the  radial  lower  fragment,  the  normal  relations 
are  no  longer  maintained  between  the  styloid  processes  of  the 
radius  and  ulna.     There  is  a  reversal  of  relations.     The  radial  sty- 


228 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


loid  is  higher  than  usual.     It  is  on  the  same  level  with  or  higher 
than  the  head  of  the  ulna. 

It  is  possible  to  have  present  a  fracture  of  the  lower  end  of  the 
radius  (a  Colles'  fracture)  without  any  appreciable  alteration  in 
the  levels  of  the  styloid  processes.     The  existence  of  the  normal 


Lower  radial  fragment  rotated. 
Scaphoid. 


First  metacarpal. 


Styloid  of  radius. 

Fig.  306.— Colles'  fracture.     Lateral  view  of  figure  305.     Rotation  of  lower  fragment  on  trans- 
verse axis.     Cause  of  dorsal  and  palmar  deformity  evident  (X-ray  tracing). 


Lower  fragment  of 
radius. 


Fig.   307. — Simple  transverse   Colles'   fracture.     Anteroposterior  view.      Lateral   deformity 

(X-ray  tracing). 


relations  of  the  styloids  does  not  preclude  the  presence  of  a  frac- 
ture. 

Direct  pressure  over  the  broken  bones  elicits  pain,  but  crepitus 
is  often  undetected  until  the  patient  is  examined  with  the  aid  of 
an  anesthetic.     A  transverse  ridge  is  sometimes  present  on  the 


o  .a 


o   o 

—       Q, 
<L>      O 


2  30 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


posterior  and  external  surface  of  the  radius,  corresponding  to  the 
line  of  fracture.  In  certain  cases  of  Colles'  fracture  the  wrist  may 
not  appear  very  unnatural.    There  may  be  scarcely  an)^  deformity. 


Radius 


Line  of  fracture. 
I 


Ulna. 


Line  of  fracture. 


Pig_  3io._Simple  transverse  Colles' fracture.     Lateral  view.     Same  as  figure  307  (Massachu- 
setts General  Hospital). 


V    1        ^, 


Styloid  process. 


Fig.  3n.— Colles'  fracture.     Fracture  of  styloid  of  ulna.     A  T-fracture  into  the  wrist-joint. 
Much  lateral  deformity  (X-ray  tracing). 


The  normal  relation  may  be  nearly  preserved.  If  there  is  little 
displacement  of  the  fragments,  it  may  be  difficult  to  determine 
the  existence  of  fracture.     An  appreciation  of  slight  differences 


COLLES'    FRACTURE — DIFFERENTIAL   DIAGNOSIS 


231 


from  the  nonnal  will,  under  these  circumslances,  prove  of  great 
value.     The  Rontgen  ray  will  be  of  service  in  this  connection. 

After  injury  to  the  wrist  one  must  consider  in  the  differential 
diagnosis — 

A  sprain  of  the  wrist,  Fracture  of  the  shaft  of  one  or  both  bones 

Contusion  of  the  bones  near  the  wrist,  low  down, 

Dislocation  of  the  wrist  Imckward.  Separation  of  the  lower  radial  epipliysis. 

A  sprain  of  the  wrist  is  rather  unusual.  There  very  often  exists 
in  so-called  sprains  a  definite  anatomical  lesion  of  bone.  The 
deformity  due  to  the  distention  of  the  synovial  sac  wath  fluid  is 


Ulna. 


Displaced  styloid  process 
of  ulna. 


Fig.  312.— Colles' fracture  with  fracture  of  base  of  ulnar  styloid;  outward  displacement 
of  styloid  fragment.  Shaft  of  radius  driven  into  the  lower  fragment  (Massachusetts  General 
Hospital,  1 173.     X-ray  tracing). 


pig_   313.— Radial   fracture  upward   and    outward    (Massachusetts    General   Hospital,    1126. 

X-ray  tracing). 


conspicuous  over  the  back  of  the  wrist- joint  and,  therefore,  near 
the  hand.  There  is  tenderness  upon  pressure  over  the  synovial 
membrane  anteroposteriorly.  There  is  little  or  no  tenderness 
over  the  radius  upon  deep  pressure.  There  is  an  absence  of  the 
positive  signs  of  fracture.  It  is  not  an  uncommon  experience 
to  find  an  injury-  to  the  lower  end  of  the  radius  presenting  no  posi- 


232 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


tive  fracture  signs,  which  is  proved  by  the  Rontgen  ray  to  be  a 
break  of  the  lower  end  of  the  radius.  A  lesion  somewhat  resem- 
bling that  shown  in  figure  304,  the  bone  being  cracked  along  those 
same  lines  but  without  displacement,  is  sometimes  found  to  exist. 
Many  of  these  obscure  lesions  are  passed  over  as  sprains  of  the 


Fig.  314.— Fracture  of  inner  edge  of  \.he  radius  (X-ray  tracing). 


Fig-  315.— Fracture  of  radial  styloid  (Massachusetts  General  Hospital,  1252.     X-ray  tracing). 


wrist.  Any  injury  to  the  wrist,  no  matter  how  trivial,  should  be 
regarded  with  suspicion  until  there  is  absolute  proof  that  fracture 
is  absent. 

A  Contusion  of  One  or  Both  Bones  near  the  Wrist-joint:  Ten- 
derness is  localized.  Fracture  signs  are  all  absent.  The  Rontgen 
ray  will  assist  in  determining  this  diagnosis. 

Dislocation  of  the  wrist  backward  is  rare.  The  posterior  promi- 
nence is  lower  down  on  the  wrist  than  in  Colles'  fracture.     The 


COLLES'    FRACTURE — DIFFERENTIAL   DIAGNOSIS 


233 


Upper  surface  of  the  displaced  carpus  can  be  felt.  The  relation  of 
the  two  styloids  is  preserved.  The  deformity  disappears  and  does 
not  tend  to  reappear  when  traction  is  made  on  the  hand  and  pres- 
sure is  made  over  the  dorsal  prominence. 

Fracture  of  the  shaft  (see  Fig.  317)  of  one  or  both  bones  low 


Radial  epiphysis,  outer 
fragment. 


Radial  epiphysis,  inner 

fragment. 
Displaced   styloid   pro- 
cess of  ulna. 
Ulnar  epiphyseal  line. 


Fig.  316. — Fracture  of  the  epiphysis  of  the  lower  end  of  the  radius  and  of  the  styloid  process 
of  ulna  (Massachusetts  General  Hospital,  712.    X-ray  tracing). 


Fig-  317- — Colles'  fracture,  with  fracture  at  lower  end  of  ulna  (^X-ray  tracing). 


down  may  simulate  the  anteroposterior  deformity  of  Colles'  frac- 
ture, but  an  absence  of  other  positive  signs  is  important.  The 
Rontgen  ray  determines  the  exact  seat  of  the  lesion.  Abnormal 
mobility  and  crepitus  are  readily  obtained  without  the  adminis- 
tration of  an  anesthetic. 


Fig.  318. — Case:   Adult.     Very  great  comminution  of  lower  end  of  the  radius.     Extremely 
difficult  to  mold  fragments  into  good  positions.     Note  abduction  of  hand. 


234 


COLLHS'    FRACTURE — ASSOCIATED   LESIONS  235 

A  Separation  of  the  Lower  Epiplusis  of  the  Radius:  The  lower 
epiphysis  of  the  radius  unites  with  the  shaft  about  the  twentieth 
year.  The  radius  increases  in  length  chiefly  through  growth 
from  its  lower  epiphysis.  This  lesion  occurs  much  more  commonly 
than  has  hitherto  been  supposed.  It  is  usually  classed  as  a  Colles' 
fracture,  no  very  careful  examination  being  made.     There  is  usu- 


Fig.  319.— Reduction  of  Colles'  fracture.     Note  position  of  hands  in  forcibly  hyperextending 
the  lower  fragment ;  breaking  up  impaction. 


Fig.  320. — Reduction  of  Colles'  fracture.     Note  grasp  upon  forearui  aiul  the  lower  tiagment  of 
the  radius,  traction  and  countertraction  being  made;  breaking  up  the  impaction. 


ally  less  deformity  than  is  found  in  most  Colles'  fractures,  and  it  is 
nearer  the  hand.  The  crepitus  is  soft  and  cartilaginous,  and 
easily  obtained  without  an  anesthetic.  The  treatment  of  separa- 
tion of  the  lower  radial  epiphysis  is  similar  to  that  of  a  Colles'  frac- 
ture. A  fracture  of  the  lower  radial  epiphysis  is  occasionally 
seen;  it  is,  however,  a  rare  lesion  (see  Fig.  316). 


236 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


Associated  with  every  Colles'  fracture  there  may  be  one  or  more 
of  the  following  lesions :  A  fracture  through  the  lower  end  of  the 
ulna,  which  is  rather  rare  (see  Fig.  317).  A  fracture  of  the  styloid 
process  of  the  ulna,  which  occurs  in  about  fifty  to  sixty-five  per 
cent,  of  all  cases  (see  Fig.  312).  A  rupture  of  the  interarticular 
triangular  fibrocartilage  at  its  insertion  into  the  base  of  the  styloid 
process  of  the  ulna.  This  is  probably  quite  common,  and  accounts 
in  part  for  the  broadening  of  the  wrist-joint.  A  perforation  of 
the  skin  by  the  lower  end  of  either  the  ulna  or  the  shaft  of  the 
radius,  making  an  open  fracture.  A  fracture  of  the  scaphoid 
bone,  although  occurring  often  alone,  is  not  very  uncommonly  asso- 
ciated with  Colles'  fracture.     A  sprain  of  the  hand,  wrist,  forearm, 


Fig.  321. — Reduction  of  Colles'  fracture.  Note  position  of  the  thumbs  and  fingers.  Lower 
ragment  is  pushed  into  place  while  counterpressure  is  made  by  the  fingers  upon  the  upper 
fragment. 


elbow,  or  shoulder  may  occur.  It  is  wise  to  examine  the  whole 
upper  extremity,  particularly  a  few  days  after  the  accident,  as  it 
is  at  this  time  that  sprains  associated  with  fracture  are  likely  to 
be  detected. 

Treatment. — The  ordinary  uncomplicated  fracture  is  here 
under  consideration.  Reduction  should  be  accomplished  as  soon 
as  possible.  Complete  reduction  can  not  be  made  satisfactorily 
without  the  administration  of  an  anesthetic,  either  to  complete 
or  partial  anesthesia.  Very  great  force  is  needed  to  accomplish 
satisfactory  reduction  of  impacted  fractures  of  the  radius.  It  is 
because  of  the  use  of  too  little  force  that  often  a  slight  bony  de- 
formity remains  after  union  has  taken  place. 

A  Method  of  Reduction. — Grasp  with  the  thumbs  and  forefingers 


COLLES'  FRACTURE — TREATMENT  237 

of  the  two  hands  the  upper  and  lower  fragments.  Free  the  Icnver 
fragment  completely  from  the  upper  by  pressure  and  traction 
backward  and  forward  and  laterally  upon  the  lower  fragment, 
using  all  the  force  that  is  needed  (see  Figs.  319,  320).  The  lower 
fragment  may  then  be  forced  into  position  by  pressure  of  the  two 


Fig.  322. — Fracture  of  radius  near  wrist.     Method  of  applying  the  posterior  splint  and  dorsal 
pad  in  displacement  of  lower  fragment  backward. 


Fig.  323. — Fracture  of  radius  near  wrist.  Method  of  applying  anterior  splint  and  pad  and 
of  holding  the  two  splints  and  arm  for  the  application  of  straps.  Anterior  splint  is  cut  out 
below  the  thenar  eminence. 


thumbs  upon  the  dorsum  of  the  wrist  (see  Fig.  321).  W-lien 
reduction  is  completed,  the  hand  should  be  allowed  to  rest  natur- 
ally without  support  to  determine  whether  there  is  a  recurrence 
of  the  deformity.  If  there  is  no  recurrence  of  the  deformity,  the 
fracture  may  be  fixed.  If  there  is  recurrence  of  the  deformity,  no- 
tice should  be  taken  of  the  direction  of  the  displacement  of  the 


238 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


lower  fragment,  that  proper  pads  may  be  applied  to  hold  it  in 
position.  A  pad  of  compress  cloth  placed  on  the  dorsum  of  the 
wrist  over  the  lower  fragment  will  easily  hold  it  if  ordinarily  dis- 
placed. A  knowledge  of  the  direction  of  the  displacement  of  the 
lower  fragment  will  suggest  the  prevention  of  the  recurrence  of  the 
deformity.  The  Rontgen  ray  is  making  possible  a  more  intelli- 
gent treatment  of  this  fracture  of  the  radius.     The  bone  is  so 


Fig.  324. — Fracture  of  the  forearm  near  the  wrist-joint.  Anterior  and  posterior  splints. 
Straps  are  taut.  Note  length  of  splints,  the  position  of  the  three  straps,  and  the  cutting  out 
of  the  anterior  splint  to  clear  the  thenar  eminence. 


Fig.  325.— Fracture  of  the  forearm  near  the  wrist-joint.  Notice  wrinkles  in  the  straps. 
The  straps  are  loose  from  the  pressure  of  the  two  splints  together.  Thus  is  illustrated  the 
fact  that  the  straps  should  retain  splints  in  position  without  exerting  much  pressure. 


nearly  subcutaneous  that  one  can  take  advantage  of  an  accurate 
knowledge  of  the  line  or  lines  of  fracture  in  attempting  reduction 
of  the  malposition.  Intelligently  applied  force  can  now  be  used  in 
each  fracture  instead  of  the  hitherto  blind  routine  manipulation. 
Thus,  less  injury  is  done  in  setting  the  fracture,  and  better  ana- 
tomical results  are  obtained. 

It  is  well  to  restore,  if  possible,  the  prominence  of  the  lower  end 


COLLES'  FRACTURE — TREATMENT 


239 


of  the  ulna  at  the  back  of  the  wrist.  Usually,  after  a  Colles'  frac- 
ture has  healed  and  functional  usefulness  exists  in  the  wrist  and 
hand,  the  ulna  will  be  found  to  have  slumped  forward — to  have 
disappeared  from  the  dorsum  of  the  wrist.    This  can  be  prevented 


Fig.  326.— Posterior   splint  padded   with   two  thicknesses  of  sheet   wadding.     Two  straps 
Note  length  of  splint  and  position  of  straps. 


Fig.  327.— Posteiior  splint,  three  straps,  and  pad  at  the  seat  of  fracture.     Note  comfortable 
position  of  forearm  and  hand. 


2 

■ 

I 

z^M 

Bl 

jg. 

^^^^y 

Fig.  328.— Completed  dressing,  similar  to  figures  326,  327.     The  bandage  is  applied  evenly 

and  uniformly. 


partially  at  the  time  of  setting  the  fracture,  by  padding  the  ulna 
anteriorly  and  by  completely  correcting  the  radial  deformity  and 
strongly  adducting  the  hand. 

Retenth-e  Apparatus. — The  simplest  splint  is  the  best.     If  there 
is  considerable  swelling  about  the  seat  of  fracture  in  a  rather 


240       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

muscular  and  large  arm,  it  is  best  to  use  the  following  apparatus : 
Two  pieces  of  splint-wood,  one  for  the  back  and  the  other  for  the 
front  of  the  forearm,  are  provided.  The  back  or  posterior  splint 
should  extend  from  the  heads  of  the  metacarpal  bones  to  a  little 
above  the  middle  of  the  forearm  (see  Fig.  322).  The  front  or 
anterior  splint  should  extend  from  the  heads  of  the  metacarpal 
bones  to  a  little  above  the  middle  of  the  forearm  (see  Fig.  323). 
These  splints  are  padded  evenly  and  smoothly  wdth  sheet  wadding, 
retentive  pads  at  the  seat  of  the  fracture  being  used  as  needed. 
The  hand  and  forearm  are  held  in  semipronation.  The  hand  is 
adducted.  The  dorsal  splint  is  applied  and  held  in  position.  The 
anterior  splint  is  then  applied  with  the  pads,  and  all  are  held  in 
position  by  adhesive-plaster  straps.     The  arm  and  splints  are 


Fig.  329.— Hand  and  fingers  extended.  Dorsal  surface  of  torearm  and  hand  practically 
straight  and  in  the  same  plane.  The  anterior  surface  of  the  forearm  and  hand  are  rounded 
and  irregular  surfaces. 


covered  with  a  bandage.  Direct  pressure  should  be  avoided  over 
the  head  and  styloid  process  of  the  ulna  posteriorly,  in  order  to 
minimize  the  disappearance  of  the  bone  from  the  dorsum  of  the 
wrist.  A  pad  placed  anteriorly  and  laterally  over  the  lower  end 
of  the  ulna  is  often  useful  in  reducing  the  ulna  head  and  styloid. 
The  adhesive-plaster  straps  should  be  snugly  but  loosely  applied. 
They  are  intended  simply  to  retain  the  splints  in  position  (see 
Fig.  324).  After  their  application,  pressing  the  two  splints  to- 
gether should  show  that  there  is  considerable  slack  in  the  straps 
(see  Fig.  325) ;  a  springiness  should  exist  between  the  splints.  The 
necessary  pressure  on  the  splints  should  be  secured  by  the  band- 
age. The  fi  gers  are  allowed  to  be  free  and  movable.  The  arm 
is  held  in  a  sling.     The  sling  ;  hould  be  so  adjusted  as  to  receive 


COLLliS     rKACTlRIC  —  TRICATMIvNT 


241 


the  whole  weight  of  the  arm,  the  hand  lying  free  from  the  upward 
pressure  of  the  sling.  The  sling  should  be  applied  with  the  ends 
crossed  in  front  of  the  neck. 

At  the  end  of  the  first  week  in  most  cases,  in  place  of  the  two 
anteroposterior  splints,  it  will  be  wise  to  use  one  posterior  splint 
only  and  an  anterior  pad  over  the  seat  of  fracture.  The  posterior 
splint  is  applied  evenly  padded,  and  if  necessary,  a  small  pad  is 
placed  over  the  dorsum  of  the  lower  fragment.  The  splint  is  held 
in  place  by  two  adhesive-plaster  straps — one  at  the  upper  end 
of  the  splint  around  the  forearm,  the  other  around  the  metacarpal 
bones  at  the  lower  end  of  the  splint  (see  Fig.  326).  The  fracture 
should  be  held  securely  by  a  third  strip  of  adhesive  plaster  at  the 
seat  of  fracture  over  a  compress-cloth  pad,  which  fills  up  the 
anterior  hollow  of  the  radius  (see  Figs.  327,  330).     This  pad  holds 


Fig.  330. — Anterior  and  posterior  splints.     Diagram  of  pad  to  fit  the  radial  arch. 


the  fragments  securely.     A  roller  bandage  gives  even  compres- 
sion and  support  to  the  whole  arm  (see  Fig.  328). 

The  posterior  surfaces  of  the  forearm,  wrist,  and  hand  in  the 
extended  position  are  practically  in  one  plane  (see  Fig.  329) ; 
hence,  the  reasonableness  of  the  use  of  the  posterior  splint.  The 
arm  lies  naturally  upon  it.  The  anterior  surface  only  requires 
accurate  padding.  The  difficulty  in  applying  an  anterior  splint 
accurately  to  the  forearm  and  wrist  is  rendered  clear  by  the 
illustration.  The  front  of  the  forearm  and  wrist  is  a  rounded 
and  uneven  surface  (see  Fig.  329).  In  order  accurately  to  control 
the  bone  by  a  splint  applied  to  the  anterior  surface  of  the  fore- 
arm, the  padding  must  be  applied  with  greater  care  than  is  ordi- 
narily exercised.  Xo  splint  is  manufactured  that  fits  the  wrist 
accurately.  If  the  surgeon  depends  upon  manufactured  and 
molded  splints,  he  is  in  very  great  danger  of  neglecting  the 
fracture).  It  is  best  for  the  surgeon  to  use  simple  splints, 
16 


24' 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM 


and  to  hold  the  fracture  reduced  by  personally  applied  pads  and 
straps. 

Until  the  time  of  union  the  arm  should  always  be  comfortable. 
The  patient  should  be  seen,  if  convenient,  within  the  first  twenty- 
four  hours  of  the  application  of  the  splint.  Swelling  may  occur 
after  the  splints  are  applied,  causing  blueness  or  swelling  of  the 
fingers.  The  bandage  may  need  reapplying  to  relieve  this  in- 
crease of  pressure.     With  the  subsidence  of  the  primary  swelling 


Fig.  331.— Colles'  fracture.     Position  of  short  dorsal  splint  of  wood  and  palmar  pad  of  com- 
press cloth.     Note  method  of  holding  before  the  application  of  the  strap. 


Fig.  332. -Colles'  fracture.     Short  dorsal  splint  and  palmar  pad  held  in  position  by  adhesive- 
plaster  strap. 


the  bandage  naturally  loosens  and  will  require  tightening.  It 
is  rare  that  the  straps  and  padding  will  need  more  than  slight 
readjustment  during  the  first  week  of  treatment.  At  least  every 
three  days  the  pads  should  be  removed  with  great  care,  and  the 
arm  carefully  inspected.  The  alinement  of  the  fragments  is  main- 
tained by  readjustment  of  the  pads. 

Gentle  massage  should  be  instituted  to  the  fingers,  hand,  wrist, 
and  forearm  during  the  second  week.     Passive  and  active  move- 


COLLES  FRACTURE — TREATMENT 


243 


ments  of  the  fingers  and  wrist  are  to  be  made  through  the  second 
week.  During  the  second  or  third  week  it  will  be  possible  to 
shorten  the  dorsal  splint  and  also  to  increase  the  amount  of  passive 


Fig.  333. — Colles'  fracture.  Cravat 
sling  holding  wrist  improperly.  Hand 
pronated. 


Fig.  33^.— Colles'  fracture.  Cravat 
sling  holding  wrist  properly.  Hand  semi- 
supinated.  Wrist  resting  upon  ulnar  side 
with  hand  unsupported. 


Fig.  335.— Right  Colles'  fracture  in  an  old  woman.  Splints  applied  for  five  weeks  with- 
out removal.  Note  deformity  and  flattening  of  hand  and  forearm.  The  fingers  and  wrist 
are  stiff  and  swollen.     Left  hand  is  normal. 


and  active  motion.  At  the  end  of  the  second  or  third  week  the 
union  will  be  found  to  be  firm.  During  the  third  or  fourth  week 
the  splint  may  be  removed  and  the  wrist  be  supported  by  a  wooden 


244       FRACTURES  OF  THE  BONES  OF  THE  FOREARM 

dorsal  pad  (see  Figs.  331,  332)  two  inches  long  and  the  width  of 
the  wrist,  and  by  a  palmar  radial  pad  of  compress  cloth  and  strips 
of  adhesive  plaster  about  two  inches  wide.  The  middle  of  the 
plaster  should  come  at  the  line  of  the  break  in  the  bone.  After 
the  fourth  week  all  padding  may  be  removed,  and  the  wrist  sup- 
ported by  a  simple  bandage.  The  fingers  and  hand  may  be  used 
at  this  time.  After  the  removal  of  the  splint  and  while  the  arm 
is  carried  in  a  sling  great  care  must  be  exercised  lest  lateral  de- 
formity result  through  an  improper  adjustment  of  the  sling 
(see  Fig.  333).  The  forearm  should  rest  in  the  sling  upon  the 
ulnar  side,  and  the  hand,  being  unsupported,  should  be  slightly 
adducted  (see  Fig.  334). 

The  treatment  of  a  "reversed  Colles'"  fracture  (see  Fig.  296) 
will  differ  from  the  treatment  of  the  ordinary  fracture  only  in  the 
method  of  reduction  and  in  the  position  of  the  retaining  pads. 
An  anterior  (palmar)  pad  will  be  needed  over  the  lower  fragment 
and  a  posterior  (dorsal)  pad  over  the  shaft  of  the  radius. 

Prognosis  and  Result. — The  swelling  about  the  fracture  in 
elderly  people  will  persist  longer  than  in  the  young.  A  function- 
ally useful  wrist-joint  and  hand  should  follow  a  simple  uncom- 
plicated Colles'  fracture  in  healthy  young  adults.  For  some 
weeks  tenderness  ma}^  exist  over  the  styloid  of  the  ulna.  Limi- 
tation of  pronation  and  supination  may  persist  for  some  time, 
disappearing,  after  several  months,  more  or  less  completely. 
Supination  is  the  last  movement  to  be  recovered.  Limitation  of 
movement  at  the  wrist  and  in  the  fingers  is  not  incompatible  with 
a  useful  wrist- joint.  Bony  union  is  rapid — within  three  weeks. 
Care  must  be  exercised  lest  in  the  early  removal  of  support  the 
soft  callus  is  molded,  by  the  ordinary  movements  of  the  wrists 
and  hand,  into  some  permanent  deformity. 

It  is  not  uncommon  for  the  line  of  the  fracture  of  the  lower  end 
of  the  radius  to  extend  into  and  involve  the  sigmoid  cavity  of  the 
radius.  Thus  the  inferior  radio-ulnar  joint  is  involved  in  the 
fracture.  This  fact  is  of  importance,  as  it  helps  to  explain  the  limi- 
tation of  motion  in  pronation  and  supination  which  so  often  exists 
after  fracture  of  the  lower  end  of  the  radius.  Often  perfect 
supination  is  the  last  movement  to  be  recovered,  and  this  may  in 


COLLES'  FRACTURE — PROGNOSIS  245 

part  be  explained  1)\-  the  imohenieiit  of  the  inferior  radio-uhiar 
joint. 

The  destruction  of  parts  of  the  lower  fragment  of  the  radius 
may  have  been  so  complete  that  it  is  impossible  to  restore  the 
wrist  to  its  normal  shape,  and  some  bony  deformit}'  will  remain 
permanently  (see  X-ray  plate,  p.  234).  Bony  deformity  is  not 
incompatible  with  a  functionally  useful  arm.  In  many  instances 
it  is  impossible  wholly  to  prevent  a  slumping  forward  of  the 
head  of  the  ulna  and  its  corresponding  disappearance  from  the 
back  of  the  wrist.  Complete  reduction  of  the  radial  deformity 
together  with  a  frequently  re-adjusted  pad  upon  the  palmar 
surface  of  the  wrist  over  the  slumping  ulna-head  are  the  best 
methods  for  preventing  the  disappearance  of  the  ulna  from  the 
dorsum  of  the  wrist.  Some  slight  widening  of  the  wrist  will  re- 
main after  most  Colles'  fractures.  The  changes  in  the  tendon 
sheaths  about  the  fracture,  the  periarticular  adhesions  that  form, 
especially  in  elderly  people,  cause  much  more  hindrance  to  recov- 
er\'  of  function  than  do  the  bony  alterations  (see  Fig.  335).  Early 
and  persistent  massage  and  passive  motion  will  prevent  these 
changes  from  becoming  permanently  troublesome.  Old  people  are 
liable  to  have  considerable  difficulty  in  regaining  the  movements 
of  the  fingers,  on  account  of  adhesions  within  and  without  the 
tendon  sheaths.  The  continued  use  of  the  hot-air  treatment  is  of 
value  in  restoring  mobility  to  the  wrist  and  fingers. 

Colles'  fractures  that  have  bony  union  with  marked  deformity 
should  be  corrected  by  osteotomy,  if  the  wrist  is  functionally  im- 
paired. Colles'  fractures  two  or  three  weeks  old  may  be  refrac- 
tured  manually,  if  necessary,  to  correct  existing  deformity.  The 
ease  of  refracture  and  the  limits  in  time  within  which  it  is  possible 
will  vary^  with  individual  cases.  The  more  nearly  the  deformity 
in  Colles'  fracture  is  corrected  at  the  first  setting,  the  milder  will 
be  the  subsequent  pain  about  the  wrist. 


CHAPTER  XI 

FRACTURES  OF  THE  CARPUS,  METACARPUS,  AND 

PHALANGES 

FRACTURE  OF  THE  CARPUS 
Simple  fracture  of  the  carpal  bones  is  unusual.  It  is  associated 
with  other  injuries.  It  is  not  uncommonly  seen  in  crushes  result- 
ing in  open  fracture.  The  scaphoid  is  found  fractured  in  certain 
Colles'  fractures  and  in  falls  upon  the  outstretched  hand.  There 
are  many  cases  of  painful  wrist,  "rheumatism"  about  the  wrist, 


F'g-  336.— Normal  wrist.     No  injury  (X-ray  tracing). 


weak  wrist,  and  sprained  wrist  that  are  instances  of  unrecognized 
fracture  of  the  scaphoid  bone.  The  persistence  of  the  difficulty 
necessitates  a  physician's  examination.  In  these  cases  a  Rontgen- 
ray  examination  will  reveal  the  true  nature  of  the  lesion.  In  inter- 
preting X-rays  of  the  carpus  following  injury  it  must  not  be  over- 

246 


FRACTURE  OF  THE  CARPUS 


247 


looked,  as  Prof.  Thomas  Dwight  has  observed,  that  in  about  i  per 
cent,  of  all  subjects  the  scaphoid  is  divided  into  two  parts  in  the 
course  of  its  development.  Such  an  anomaly  might  be  easily 
mistaken  for  a  fracture  of  the  scaphoid  if  the  appearances  in  the 
X-ray  alone  were  depended  upon.     After  fracture  of  the  scaphoid 


Radial  fissure. 


Fig.  337. — Case:  Fracture  of  the  scaphoid  and  fissure  of  radius  (X-ray  tracing)  (Balch). 


Crack  of  ulna. 
Epiphyseal  line. 


Scaphoid  fragment. 
Scaphoid  fragment. 


Epiphyseal   line   of 
radius. 


Fig.  33S. — Fracture  of  the  scaphoid.     Lesion  of  epiphysis  of  ulna  (X-ray  tracing)  (Balch). 


bone  persistent,  painful  limitation  of  extension  at  the  wrist  is  not 
at  all  uncommon.  The  os  magnum  is  sometimes  fractured  by 
falls  upon  the  hand. 

Treatment. — If  there  is  displacement,  immediate  pressure  and 
counterpressure,  associated  with  extension  and  flexion  of  the 
wrist-joint,  under  an  anesthetic  will  usually  reduce  the  displace- 


248   FRACTURES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

ment.  Immobilization  of  the  wrist-joint  should  be  secured  by 
means  of  a  dorsal  splint  extending  from  above  the  middle  of  the 
forearm  to  the  heads  of  the  metacarpal  bones  (see  Fig.  326).  It 
should  be  retained  by  two  adhesive-plaster  straps.     Sheet  wad- 


Fig.  339.— Fracture  of  the  scaphoid.     The  two  fragments  are  seen  near  the  styloid  of  the 
radius  (X-ray  tracing)  (Balch). 


Scaphoid  fragment. -> C^  r 

Scaphoid  fragment. -^     ' 


Fig.  340.— Case  :  Fracture  of  the  scaphoid  (X-ray  tracing). 


ding  and  gauze  roller  bandages  are  then  carefully  applied  to  the 
arm  the  whole  length  of  the  splint  (see  Fig.  328). 

With  the  splint  in  position  gentle  massage  to  the  wrist  and  fore- 
arm after  the  first  week  will  hasten  healing.     Gentle  passive  mo- 


SYMPTOMS 


249 


lion  with  iiiuR'  vi.^orous  inassaj^c  will  be  iiulicaU-d  at  the  end  of 
two  weeks.  At  the  vud  of  tlirrc  or  four  weeks  all  supi)ort  save  a 
roller  bandage  may  be  omitted.  vStiffness  will  persist  after  this 
injury,  especially  in  elderly  people  (see  Figs.  336-340  inclusive). 

FRACTURE  OF  THE  METACARPAL  BONES 
The  third  and  fourth  metacarpal  bones  are  the  ones  most  com- 
monly broken.     The  fracture  is  due  to  a  blow  upon  the  knuckles 

(see  Fig.  341). 

Symptoms.— The  deformity   is  characteristic.     The  very  con- 
siderable swelling  often  obscures  the  outline  of  the  bones,  but  pal- 


Fig.  341.— Metacarpus  and  phalanges 
showing  epiphyses  at  fifteen  years  (Warren 
Museum,  specimen  537). 


Fig.342.— Fracture  of  third  metacarpal, 
showing  dropping  of  knuckle.  Ligament- 
ous preparation. 


pation  detects  the  lower  end  of  the  upper  fragment  in  the  dorsum 
of  the  hand,  while  the  upper  end  of  the  lower  fragment  is  some- 
times felt  in  the  palm  of  the  hand  (see  Fig.  342).  This  deformity 
is  characterized  by  a  loss  from  the  line  of  the  knuckles  of  that 
knuckle  corresponding  to  the  fractured  metacarpal  (see  Figs.  343, 
344).  Pain  and  crepitus  are  present.  The  hand  can  not  be  closed 
tightly  on  account  of  the  swelling  and  pain. 


250       FRACTUREIS  OF  CARPUvS,  MEITACARPUS,  AND  PHALANGES 

To  obtain  crepitus  easily  and  to  assist  in  reducing  the  fracture, 
it  is  best  to  grasp  the  finger  corresponding  to  the  fractured  meta- 
carpal with  the  whole  right  hand,  steadying  the  injured  metacarpus 


P'S-  343- — A,  Fracture  of  neck  of  fourth  metacarpal  bone.  Swelling  of  finger  and  knuckle. 
Knuckle  has  dropped  downward  toward  the  palm.  B,  Normal  hand.  Line  of  knuckles 
shown.     Contrast  with  A. 


A 

B 

i« 

1 

'  '  '  ^ ;  /^  • 

'  ^  '^'il>tt;iES» 

■  f  '<  '  'x 

'i^^^^^B 

Fig.  344. — Fracture  of  the  fourth  metacarpal  bone.  View  of  two  hands  from  behind  :  A, 
Normal  line  of  knuckles.  B,  Knuckle  of  the  ring-finger  has  dropped  downward.  Deformity 
well  shown. 


with  the  left  hand,  and  then  to  make  steady  and  continuous  trac- 
tion (see  Fig.  344) .  The  distal  fragment  is  so  short  and  movable  that 
unless  this  method  is  used  to  steady  the  fragment  it  will  be  difificult 
to  determine  crepitus  and  to  reduce  the  fracture.     This  fracture 


Fig.  345.— Method  of  grasping  hand  and  finger  in  examining  for  fracture  of  metacarpal  bone, 
and  in  reducing  such  a  fracture. 


Fig.  346.— Fracture  of  the  neck  of  the  second  metacarpal.  Method  of  securing  extension. 
Note  adhesive  plaster,  rubber  tubing,  peg,  padding  to  finger,  pad  over  proximal  fragment. 
Counterextension  by  adhesive  plaster  about  wrist.     Ready  for  the  application  of  a  bandage. 


Pig-  347-- 


-Fracture  of  the  metacarpal  of  the  index-finger.     Use  of  roller  bandage.     Position 
of  roller  bandage.    Method  of  traction  and  countertraction. 

251 


2  52        FRACTURES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

heals  readily.     Occasionally,  however,  a  suppurative  process  may 
complicate  recovery  even  when  the  fracture  is  not  an  open  one. 


Fig.  348.— Fracture  of  the  metacarpal  of  the  index-finger.     Completion  oi  traction.     Pressure 
and  counterpressure  by  thumb  on  the  dorsum  and  on  bandage  in  the  palm  of  the  hand. 


Fig.  349.— Fracture  of  the  metacarpal  of   the  index-finger.     Completion  of  the  application  of 
the  dressing.    Adhesive-plaster  straps  holding  hand  and  roller  bandage  in  position. 


Bennett's  fracture,  commonly  designated  "  stave  "  of  the  thumb, 
should  be  mentioned  here.  It  is  a  fracture  of  the  proximal  end 
of  the  metacarpal  of  the  thumb,  oblique  and  into  the  joint  with 


TREATMENT 


253 


the  trapezium.  (See  figure  of  X-ray,  No.  352.)  Tlie  metacarpal 
bone  is  displaced  backward.  There  is  great  disability  in  opposing 
the  thumb  and  index-finger.  Grasping  small  objects  is  impos- 
sible.     Pressure  upon  the  ball  of  the  thumb  is  painful. 

The  injuries  likely  to  be  mistaken  for  this  fracture  are  subluxa- 
tion of  this  same  joint,  a  sprain  of  this  joint,  and  a  contusion  of  this 
part. 

Treatment. — After  reducing  the  fracture  by  traction  and  pres- 
sure as  suggested,  it  must  be  held  in  place  by  special  padding,  for 


Fig.  350. — Transverse  fractures  of 
the  last  three  metacarpals  (X-raj'  trac- 
i'lg). 


P'S-  351- — Oblique  fracture  of  the  third 
and  fourth  metacarpals  (Massachusetts 
General  Hospital,  1142.     X-ray  tracing). 


the  deformity  tends  to  recur.  The  hand  and  forearm  are  sup- 
ported upon  a  properly  padded  palmar  splint.  A  pad  is  placed  in 
the  palm  over  the  prominent  lower  end  of  the  metacarpal.  An- 
other pad  is  placed  upon  the  dorsum  of  the  hand  over  the  upper 
fragment.  These  pads  are  secured  by  narrow  strips  of  adhesive 
plaster.  The  whole  is  then  bandaged.  If  after  carefully  padding 
the  two  fragments  and  immobilizing  them  the  deformity  is  repro- 
duced, the  fragments  slipping  by  each  other,  it  may  be  necessar\^  to 
make  permanent  traction  upon  the  finger  (see  Fig.  346).  This  is 
best  done  by  applying  narrow  adhesive-plaster  straps  to  the  sides 


Proximal  fragment 


Fig.  352. — Fracture  of  the  upper  end  of  metacarpal  bone  of  thumb.  Displaced  upper 
fragment  could  be  felt  in  the  palm  of  the  hand  (  Massachusetts  General  Hospital,  1785. 
X-ray  tracing). 


Phalangeal  epiphysis.  — 


Normal  epiphyseal  line  — 
and  epiphysis. 


—  Phalanx. 


~"  Separated  epiphysis 

second  metacarpal. 


Fig-  353- — Separation  of  the  distal  epiphysis  of  the  second  metacarpal  bone.  Displace- 
ment into  the  palm  of  the  hand.  Rare  (Massachusetts  General  Hospital,  1765.  X-ray 
tracing). 


Fig-  354- — Fracture  of  terminal  phalanx  of  thumb.     Anteroposterior  and  lateral  views  (X-ray 

tracings). 
254 


TREATMENT 


'55 


of  the  finger  licld  in  ])lace  b\-  circular  and  oblique  straps.  The 
hand  rests  upon  the  ])almar  s])lint.  An  adhesi\"e-plaster  circular 
band  passed  about  the  wrist  and  si)lint  ofl'ers  continuous  counter- 
traction.  If  the  band  is  carried  between  the  thumb  and  forefinger, 
greater  security  is  obtained,  and  there  is  much  less  likelihood  of 
slipping  of  the  plaster.  The  extension  upon  the  finger  is  obtained 
by  fastening  the  extension  strips  to  small  pieces  of  rubber  tubing, 
and  carrying  the  tubing  around  a  wooden  peg  or  screw  passed 
through  a  hole  in  the  splint. 


Fig.  355.  —  Fracture  of  the  finger. 
Wooden  splint  applied  to  the  palmar  sur- 
face.    Note  straps  and  length  of  splint. 


Fig-  356- — Finger    splint    ot    copper    wire 
applied. 


A  simple  contrivance  for  a  fracture  with  little  displacement  is 
the  use  of  a  roller  bandage  (see  Figs.  347-349  inclusive).  A  roller 
bandage  of  cotton  cloth  that  is  firm  and  not  easily  compressed  and 
of  a  size  comfortable  for  the  hand  to  grasp  is  selected.  This  is 
placed  in  the  palm  of  the  extended  hand ;  the  fingers  and  metacar- 
pal heads  are  drawn  down  firmly  over  it.  This  position  is  main- 
tained by  a  broad  strip  of  adhesive  plaster  around  the  whole  hand. 
Pads,  as  with  the  palmar  splint,  mav  be  used  to  reinforce  the  roller 
bandage.  Unless  great  care  is  exercised,  this  method  will  result  in 
posterior  bowing  of  the  metacarpal  bone.     If  there  is  an  anterior 


Fig-  357- — A,  Finger  splint  of  aluminium  or  tin,  anterior  surface.     B,  Finger  splint  applied  to 
middle  finger,  three  straps.     Note  position  of  splint  in  palm  of  hand. 


Fig.  358.— Palmar  wooden  thumb  splint.     Note  shape,  pads,  straps,  position. 

256 


FRACTURE  OF  THE  PHALANGES  257 

displaceuK'nt  of  either  or  both  fragments,  this  roller-bandage  ap- 
paratus is  very  eflicient  in  maintaining  reduction  of  the  deformity. 
This  apparatus  should  be  carefully  inspected  each  day  during  the 
first  week,  to  be  sure  that  the  position  obtained  is  held  firmly. 
After  three  weeks  the  splint  may  be  omitted.  Massage  during  the 
third  week  will  be  of  benefit.  Great  care  must  be  exercised  in  the 
use  of  the  hand  following  the  removal  of  the  splint  until  the  fourth 
week  is  passed,  for  deformity  may  result  (see  Figs.  350-353  inclu- 
sive). 


FRACTURE  OF  THE  PHALANGES 

The  bones  lie  subcutaneously ;  fractures  of  the  phalanges  are, 
accordingly,  comparatively  easy  to  detect.     Fractures  near  the 


Fig-  359— Lateral  splint  of  wood  for  fracture  of  the  thumb.     Note  pad  at  the  side  of  first 
phalanx,  to  correct  lateral  deformity. 


articular  surfaces  are  hard  to  detect  because  joint  crepitus  is  de- 
ceptive. The  so-called  base-ball  finger  may,  in  many  instances, 
be  associated  with  a  fracture  of  the  head  of  the  metacarpal  bone, 
and,  involving  the  joint,  occasion  a  slow  convalescence  (see  Fig. 
342)- 

Symptoms. — Crepitus,  pain,  and  abnormal  mobility  are  pres- 
ent, and  occasionally  deformitv  is  seen. 

Treatment. — It  is  important  that  the  alinement  of  the  phalanx 
17 


258       FRACTURES  OF  CARPUS,  METACARPUS,  AND  PHALANGES 

be  maintained.  Rotation  of  the  lower  fragment  upon  its  long  axis 
is  especially  to  be  guarded  against.  Temporarily,  if  there  is  much 
swelling,  the  broken  finger  may  rest  upon  a  palmar  splint,  the  two 
adjoining  fingers  serving  as  lateral  splints  to  steady  it.  The  con- 
tiguous skin  surfaces  must  be  protected  by  strips  of  cotton  cloth 
and  a  drying  powder. 

A  single  splint  of  thin  wood,  extending  from  the  middle  of  the 
palm  of  the  hand  to  the  finger-tip,  and  held  in  position  by  adhesive- 
plaster  straps,  is  most  useful  (see  Fig.  355).  The  splint-wood  used 
should  be  cut  thin  and  not  left  thick  and  bungling — half  the  thick - 


Fig.  360. — Thumb  splint :  a,  Pattern— measurements  are  in  inches  ;  5,  position  of  splint.     Note 
extension  of  thumb  (after  Goldthwaite). 


ness  of  the  wood  of  an  ordinary  cigar  box  is  about  right.  The 
splint  should  be  a  little  narrower  than  the  finger  itself.  A  narrow 
cotton  bandage  applied  over  the  finger  or  a  simple  cot  to  cover  the 
finger  will  be  comfortable  and  will  assist  in  immobilization.  Or- 
dinary letter-paper,  by  continued  folding,  may  be  made  into  a 
narrow  and  suitable  splint.  This  is  simple  and  efficient.  It  should 
be  held  in  place  by  a  bandage  or,  preferably,  by  a  cot.  Ordinary 
copper  wire  may  be  used,  as  shown  in  the  illustration,  without  any 
padding  (see  Fig.  356).  This  serves  as  a  proper  protection  after 
the  first  week  or  two,  and  is  not  so  clumsy  as  other  splints.  The 
aluminium  or  tin  finger  splint  is  easily  made  and  satisfactory  (see 


OPEN    FRACTIKE    oi"    TIIH    I'HAKANGIvS  259 

^'ig-  357)-  An\-  (lis])lacenR-nl  in  this  rraclure  may  be  easily  ad- 
justed by  narrow  adhesive  straps  and  small  pads. 

Fractures  of  the  iirst  and  second  phalanges  of  llie  thumb  may 
be  satisfactorily  treated  after  reduction  upon  a  dorsal  or  lateral 
splint  of  wood,  if  proper  padding  is  em])loyed  (see  Figs.  358,  359). 
Frequently,  however,  the  tin  splint  filled  to  Ihe  cleft  between  the 
thumb  and  forefinger,  as  shown  in  the  illustration  (Fig.  360),  will 
immobilize  these  fractures  more  securely  and  comfortably. 

Open  Fractures  of  the  Phalanges.— This  is  usually  followed 
by  profuse  suppuration  from  necrosis  of  the  fractured  bones.  This 
fracture  is  to  be  treated  with  extreme  care,  especially  as  regards 
antisepsis.  Immobilization  should  continue  at  least  four  weeks. 
If  at  the  end  of  this  time  union  has  not  occurred,  the  patient  may  be 
given  the  option  of  continuing  the  treatment  or  of  having  the  finger 
amputated.  If  union  does  not  occur  after  four  weeks  of  careful 
treatment,  it  is  highly  improbable  that  it  will  ever  occur.  Resec- 
tion of  the  bones  may  be  attempted  before  amputation. 


CHAPTER  XII 
FRACTURES  OF  THE  FEMUR 

FRACTURE  OF  THE  HEP  OR  NECK  OF  THE  FEMUR 
Anatomy. — The  crest  of  the  ihum  can  be  felt  throughout  its 
entire  extent,  from  the  anterior  superior  spine  to  the  posterior 
superior  spine.  The  posterior  superior  spine  corresponds  to  the 
level  of  the  center  of  the  sacro-iliac  synchondrosis.  The  great 
trochanter  of  the  femur  is  easily  distinguished  even  in  fat  individ- 
uals. Nelaton's  line  is  determined  by  stretching  a  tape  from  the 
anterior  superior  spine  of  the  ilium  to  the  tuberosity  of  the  ischium 
(see  Fig.  361).  The  top  of  the  great  trochanter  lies  at  or  a  little 
below  Nelaton's  line,  and  about  opposite  to  the  symphysis  pubis. 


Fig.  361. — Nelaton's  line  (dotted  line),  from  the  anterior  superior  spine  of  the  ilium  to 
the  tuberosity  of  the  ischium.  Brj'ant's  triangle  seen.  Distance  from  top  of  trochanter  to 
perpendicular  dropped  from  anterior  spine  (X)  is  Bryant's  measurement.  After  fracture  this 
measurement  may  be  less  than  normal. 


The  internal  condyle  of  the  femur  looks  in  the  same  general  direc- 
tion as  the  head  and  neck  of  the  femur  (see  Figs.  362,  363).  The 
anterior  superior  spine  of  the  ilium  is  of  importance  because  from 
it  measurement  is  made  in  taking  the  length  of  the  legs  after  frac- 
ture of  the  femur.  Normally,  the  fingers  can  be  hooked  behind 
the  great  trochanter  toward  the  posterior  surface  of  the  neck  of  the 
bone.  By  this  manipulation  the  posterior  portion  of  the  capsule 
of  the  joint  can  be  felt. 

Fracture  of  the  Neck  of  the  Femur  in  Adults. — This  accident 
occurs  most  frequently  in  elderly  people.     It  ordinarily  is  associ- 

260 


SYMPTOMS 


261 


ated  with  a  vcrv  slij^hl  injury,  such  as  a  trip  and  fall  upon  the  floor 
from  the  standing  position.  Undoubtedly,  in  man},-  instances 
the  fracture  precedes  the  fall.  It  is  often  dillkult  to  determine 
the  exact  seat  of  the  lesion.  \\'hether  the  fracture  is  within  or 
without  the  capsule  of  the  joint  is  of  comparatively  little  moment. 
On  the  other  hand,  whether  the  fracture  is  impacted  or  unim- 


Fig.  362.  —  Femur,  from  front.  Note 
normal  relation  of  direction  of  head  and 
neck  to  that  of  internal  condyle. 


V' 


Fig.  363.  —  Femur,  from  outer  side. 
Note  normal  anterior  bowing  and  relation 
of  direction  of  head  and  neck  to  that  of  in- 
ternal condyle. 


pacted  is  of  the  greatest  importance.  Fractures  of  the  base  of  the 
neck  of  the  bone — that  is,  fractures  near  the  trochanter — are 
usually  impacted.  Fractures  of  the  neck  toward  the  head  of  the 
bone  are  usually  unimpacted  (see  Fig.  365).  Impacted  fractures 
unite  readily.     Unimpacted  fractures  often  remain  ununited. 

Symptoms. — The  patient  is  unable  to  rise  from  the  ground.     A 
contusion  may  be  seen  over  the  hip  as  a  result  of  the  fall.    There  is 


262 


FRACTURES    OF    THE    FEMUR 


pain  in  the  hip  while  the  patient  is  lying  still.  This  pain  is  increased 
upon  motion  at  the  hip.  There  is  an  inability  to  move  the  injured 
leg  easily  and  painlessly.  There  is  limitation  of  motion  of  the  in- 
jured leg.  While  lying  upon  the  back  it  is  impossible  for  the  pa- 
tient to  raise  the  heel  from  off  the  bed.  The  foot  is  everted,  the  leg 
having  rolled  outward.  The  whole  extremity  lies  helpless  (see  Fig. 
366).  There  is  a  slight  appreciable  fullness  below  the  fold  of  the 
groin.  This  fullness  in  the  outer  upper  part  of  Scarpa's  triangle 
corresponds  to  a  non-depressible  area  associated  with  fracture  of 
the  neck  of  the  femur.  Slight  shortening  of  the  leg  exists.  After 
three  or  four  days  this  shortening  may  increase  to  two  inches.    The 


Fig.  364. — Upper  end  of  femur  in  a 
child:  fl,  a,  Line  of  junction  of  epipliysis 
of  head  and  shaft;  b,  epiphysis  of  greater 
trochanter;  c,  epiphysis  of  lesser  trochan- 
ter (Warren  Museum,  specimen  334). 


Fig.  365. — Head  and  neck  of  femur  of 
adult.  The  lines  show  the  ordinary  seats 
of  fracture. 


trochanter  is  above  Nelaton's  line.  The  fascia  above  the  tro- 
chanter is  relaxed  (see  Fig.  367).  This  is  especially  noted  in  the 
standing  position,  with  the  patient  resting  the  weight  upon  the 
well  leg.  If  the  fracture  is  an  impacted  one,  crepitus  will  be  ab- 
sent upon  gentle  manipulation,  unless  the  impaction  has  been 
broken  up  by  some  unwise  means.  If  the  fracture  is  unim- 
pacted,  crepitus  can  be  detected  by  the  hand  while  traction  or 
gentle  rotation  of  the  leg  is  made.  The  foot  is  everted  whether 
impaction  is  present  or  not.  If  the  impaction  is  of  the  anterior 
portion  of  the  neck,  inversion  will  be  present ;  if  the  impaction  is 
of  the  posterior  portion  of  the  neck,  eversion  will  be  present  (see 


FRACTURK    ()K    Till';    HIP — EXAiMINATION  263 

Figs.  ,^68,  369).  Impacted  eversion  can  not  be  inverted  nor  can 
impacted  inversion  be  everted  without  breaking  up  the  impaction. 
In  these  cases  of  marked  eversion  and  inversion  a  dislocation  of 
the  hi])  nuist  be  exchulcd  if  possible. 

Examination. — A  prolonged  search  for  crepitus  and  abnormal 
mobility  must  never  be  attempted.  In  order  to  avoid  unnecessary 
movement  of  the  hip  and  because  inspection  and  gentle  palpation 
alone  will  so  often  decide  the  diagnosis,  it  is  wise  to  follow  a  routine 
examination. 

The  history  of  the  accident  should  be  obtained.  The  presence 
and  location  of  pain  are  determined.  How  much  is  the  functional 
usefulness  of  the  leg  involved  ?  What  does  inspection  reveal  as  to 
the  local  condition  and  the  position  of  the  limb?     What  does  pal- 


Fig.  366.— Case  :    Impacted   fracture  of   the  left   hip.     Note  helpless   attitude  of  limb  ;    foot 

everted. 


pation  reveal?  How  do  the  measurements  of  the  leg  and  the  tro- 
chanter compare  with  similar  measurements  of  the  uninjured  leg? 
Last, — and  to  be  avoided  if  a  diagnosis  has  been  reached, — what 
does  gentle  manipulation  show  as  to  the  presence  of  crepitus  in  the 
hip? 

In  order  to  make  a  systematic  examination  all  clothing,  of  course, 
should  be  removed  from  the  patient.  He  then  should  be  placed 
upon  a  firm  and  even  surface.  A  hard  mattress,  a  table,  or  a  com- 
forter spread  upon  the  floor  will  provide  the  necessary  conditions. 
An  anesthetic  is  hardly  ever  necessary  for  diagnostic  purposes.  If 
an  anesthetic  is  employed,  the  hip  should  be  handled  in  the  gentlest 
manner  possible.  All  muscular  spasm,  which  without  an  anes- 
thetic protected  the  hip  from  violence,  is  abolished  ;  therefore,  move- 
ments of  the  hip  are  felt  directly  by  the  bone  unprotected  by  mus- 


264 


FRACTURES    OF   THE   FEMUR 


cular  spasm.  All  sudden  quick  movements  should  be  avoided. 
There  is  great  danger  that  an  impacted  fracture  of  the  hip  may  be 
changed  by  rough  handling,  especially  in  the  movement  of  rota- 
tion, to  an  unimpacted  fracture.  Palpation  of  the  neck  of  the 
femur  with  the  thumb  in  front  of,  and  the  fingers  behind,  the  great 
trochanter  will  detect  any  irregularity  or  thickening  and  tender- 
ness about  the  neck  of  the  bone  (see  Fig.  377).  By  palpation  of 
the  great  trochanter  one  may  discover  there  the  seat  of  fracture. 


F'g-  367.— Relaxation  of  the  fascia  lata  as  a  result  of  fracture  of  the  hip.     Most  obvious  at 
point  shown  by  the  arrow. 


Swelling,  tenderness,  and  crepitus  may  be  found.  Only  gentle 
strong  traction  in  the  line  of  the  long  axis  of  the  thigh  should  be 
made  to  elicit  crepitus  and  abnormal  motion. 

Measurement. — The  absence  of  any  preexisting  injury  or  disease 
of  the  hip  under  consideration  is  always  to  be  carefully  noted. 
Measurement  should  always  be  made  with  the  patient  lying  on  the 
back.  The  leg  should  be  brought  gently  alongside  of  its  fellow, 
and  steadied  by  an  assistant.  Measurement  should  be  made  from 
the  anterior  superior  spine  of  the  ilium  to  the  internal  malleolus 


FRACTl'RU    OF    TIIIC    HIP — MKASUKKMKNT 


265 


upon  each  side  (see  Fig.  397).  If  lliere  is  sliorleniii.i;  U])()n  tlie 
ini'iired  side,  a  fracture  with  some  displacenienl  is  likel\-  to  have 
occurred.  A  normal  diflVrence  in  the  length  of  the  lower  limbs  is, 
however,  not  unusual.  It  is,  therefore,  necessary  to  determine  the 
presence  of  asymmetry  if  it  exists,  if  any  confidence  is  to  be  placed 
in  the  measurements  of  the  legs.  Measurements  should,  therefore, 
be  made  of  tl»e  tibia  upon  the  two  sides,  and  these  compared.  If 
no  asymmetry  appears  to  be  present,  any  differences  in  measure- 


Fig.  368. — Fracture  of  the  hip.  Inward 
rotation  of  the  leg  because  of  impaction  of 
the  anterior  portion  of  the  neck  of  the 
bone. 


Fig.  369. — Fracture  of  the  hip.  Out- 
ward rotation  of  the  leg  because  of  impac- 
tion of  the  posterior  portion  of  the  neck  of 
the  bone. 


ment  may  be  taken  to  be  absolute.  If  it  is  impossible  to  bring 
the  legs  parallel,  they  must  be  placed  in  the  same  relative  positions 
to  the  median  line  of  the  body. 

Bryant's  method  of  measurement  is  simple  and  of  service  (see 
Fig.  361).  The  limbs  are  placed  symmetrically.  The  top  of  the 
trochanter  is  marked  upon  the  skin.  A  perpendicular  line  is 
dropped  from  the  anterior  superior  spine  to  the  table  upon  which 
the  patient  lies.     Measurement  is  made  from  the  top  of  the  tro- 


266 


FRACTURES    OF    THE    FEMUR 


chanter  to  this  perpendicular  line.  If  fracture  of  the  neck  of  the 
femur  has  occurred,  and  there  is  displacement  or  shortening  of  the 
limb,  the  distance  from  the  perpendicular  to  the  top  of  the  tro- 


Fig.  370. — Old  fracture  of  femoral  neck  ; 
no  union.  Absorption  of  whole  neck  of 
bone.  The  contiguous  surfaces  of  the  frag- 
ments are  of  hard,  compact  bone.  There 
is  some  atrophy  of  the  whole  shaft  of  the 
femur  (Warren  Museum,  specimen  8075). 


Fig.  372. — Fracture  between  neck  and 
shaft  and  fracture  of  great  trochanter. 
Union  so  imperfect  that  fragments  separ- 
ated in  maceration  (Warren  Museum,  spe- 
cimen 1075). 


Fig.  371. — Fracture  of  femoral  neck. 
Impaction  of  base  into  the  shaft,  with  down- 
ward and  inward  rotation  of  upper  frag- 
ment (Warren  Museum,  s]  ecimen  6303). 


Fig.  373. — Fracture  of  the  neck  of  the 
femur  and  of  the  great  trochanter  in  sec- 
tion. Impaction;  union  not  firm  (Warren 
Museum,  specimen  5225). 


chanter  will  be  less  than  a  like  measurement  on  the  uninjured  side. 
The  position  of  the  top  of  the  great  trochanter  is  determined  with 
reference  to  Nelaton's  line  (see  Fig.  361).  If  the  leg  is  rolled  out- 
ward, dislocation  of  the  hip  forward  would  be  suspected,  but  the 


FRACTrRE  OF  THE  HIP  — MEASUREMENT 


.67 


absence  of  the  heatl  of  the  bone  anteriorly  and  the  absence  of  other 
positive  signs  should  eliminate  dislocation.  If  the  leg  is  rolled  in- 
ward, a  dislocation  of  the  hip  upon  the  dorsum  ilii  would  be  con- 
sidered. The  absence  of  other  positive  signs  of  dislocation  and  the 
presence  of  the  head  of  the  bone  in  the  acetabulum  should  con- 


Fig.  374. — Fracture  of  femoral  neck, 
unimpacted  ;  fibrous  union,  with  absorption 
of  the  neck  (Warren  Museum,  specimen 
3651)- 


Fig.  375. — Old  impacted  fracture  of  the 
hip  ;  penetration  of  the  inner  wall  of  the 
neck  into  the  head  of  the  bone;  displace- 
ment and  rotation  of  the  head  downward 
and  inward  (Warren  Museum,  specimen 
10S6). 


Pig.  376.— Fracture  of  hip  :  impaction  of  neck  of  bone  into  the  head  ;  rotation  of  head  down- 
ward and  backward  ;  view  from  behind  (Warren  Museum,  specimen  10S6). 


vince  one  of  the  nonexistence  of  dislocation.  In  an  elderly  person 
who  presents  no  well-marked  sign  of  fracture,  but  who  is  unable  to 
use  the  limb  after  ever  so  slight  an  injury,  a  fracture  of  the  hip 
should  be  so  strongly  suspected  that,  until  the  Rontgen  ray  proves 
it  absent,  he  should  be  treated  as  if  a  fracture  were  present. 


268  FRACTURES    OF   THE   FEMUR 

Prognosis  and  Result. — In  the  very  aged  and  feeble  the  shock  of 
a  fracture  of  the  neck  of  the  femur  is  severe.  The  danger  to  life 
in  these  cases  is  great.  An  elderly  patient  may  die  of  shock  within 
two  or  three  days,  or  within  a  week  of  hypostatic  pneumonia,  or 
he  may  live  several  weeks  and  die  of  exhaustion  because  of  pain 
and  the  enforced  confinement.  If  the  fracture  can  be  treated  with 
proper  immobilization,  union  will  occur  in  most  cases.  The  im- 
pacted cases  will  unite ;  the  unimpacted  cases  may  unite.  Slight 
shortening  with  a  little  deformity,  some  limitation  in  the  move- 
ments of  the  hips,  a  limp,  but  a  fairly  useful  limb,  are  to  be  hoped 
for  (see  Fig.  378).  Chronic  rheumatism  will  often  prevent  a  frac- 
tured hip  from  ever  becoming  useful. 

Nonunion  of  the  hip-fracture  does  not  preclude  a  useful  limb 
(see  Fig.  379).     Ununited  fractures  of  the  hip  are  greatly  benefited 


Fig.  377. — Method  of  palpating  tiie  trochanter  of  the  right  femur. 

by  proper  ambulatory  apparatus.  They  may  be  made  to  unite  by 
mechanical  means  even  several  weeks  and  months  after  the  injury. 
This  is  particularly  true  of  fractures  occurring  in  young  adults. 

Results  after  Fracture  of  the  Hip. — Of  especial  value  in  this  con- 
nection are  the  conditions  existing  in  sixteen  cases  of  fracture  of 
the  hip,  many  years  after  the  accident.  These  sixteen  cases  were 
treated  at  the  Massachusetts  General  Hospital  by  gentle  traction 
and  immobilization,  for  periods  varying  from  a  few  weeks  to  a  few 
months.  The  patients  then  went  about  with  crutches.  No  other 
treatment  was  used.  Nearly  all  the  cases  were  unimpacted  either 
primarily  or  secondarily.  At  the  time  of  the  accident  seven  cases 
were  between  forty-two  and  forty-seven  years  old,  the  remainder — 
with  two  exceptions,  whose  ages  are  not  stated — were  over  fifty ; 
three  wer£  over  sixty  years  old.     These  cases  reported  for  exami- 


FRACTURK    OF    TIIF;    HIP — PROGNOSIS 


269 


nation  from  two  and  one  hall"  to  twenty  fonr  and  one-half  years 
after  the  accident.  Thirteen  of  the  sixteen  cases  have  impairment 
of  the  functional  usefulness  of  the  leg;  a  weakness  of  the  limb, 
necessitating  a  crutch  in  many  instances;  all  movements  at  the 
hip  somewhat  restricted ;  atrophy  of  the  muscles  of  the  thigh, 
buttock,  and  calf  of  the  leg ;  a  decided  limp,  requiring  a  cane ;  pain 
in  the  hip  extending  down  the  thigh  even  to  the  sole  of  the  foot ; 
pain  at  night  in  the  hip;  pain  in  going  up-stairs  and  in  stooping 


Fig.  378. — Deformity  following  an  old  frac- 
ture of  the  hip. 


Fig.  379.— Case  :  Man,  forty-five  years 
old.  Fracture  of  the  neck  of  the  femur. 
Union  ligamentous,  with  displacement. 
Useful  limb  (X-ray  tracing). 


over.     In  only  two  cases  out  of  the  sixteen  could  it  be  said  that  the 
leg  was  functionally  useful. 

Treatment. — General  Considerations. — Fractures  of  the  hip  or 
of  the  neck  of  the  femur  demand  the  greatest  tact  in  their  manage- 
ment. The  aged  respond  readily  to  care.  The  patient  should  be 
made  to  feel  as  comfortable  as  possible  while  confined  to  his  bed. 
Particular  attention  should  be  paid  to  diet  and  to  all  little  comforts. 
The  discomforts  attendant  upon  immobilization  are  often  very 
great.     Let  the  days  spent  in  bed  be  made  especially  attractive. 


2  70 


FRACTURES   OF   THE    FEMUR 


Be  sure  that  agreeable  friends  visit  the  patient,  seeing  to  it  that 
they  do  not  stay  so  long  a  time  as  to  weary  him.  I^et  them  inter- 
est him  in  the  news  of  the  day,  so  that  he  ma}^  feel  that  he  is  keep- 
ing up  with  events.  Employ  a  skilled  nurse  to  minister  to  his 
wants ;  a  bright  and  cheerful  woman  nurse  is  ordinarily  better  than 
a  man  nurse.  The  pulse  is  to  be  carefully  watched  as  well  as  the 
respiration.     A  moderate  amount  of  alcohol  once  or  twice  a  day 


Fig.  380. — Case  :  Fracture  of  the  neck  of  the  femur  (X-ray  tracing). 


with  meals  is  to  be  used.  The  courage  of  the  aged  needs  bracing. 
Bed-sores  develop  with  surprising  rapidity.  Skilled  watchfulness 
and  immediate  treatment  will  often  check  the  progress  of  a  red 
pressure  spot.  The  part  exposed  to  pressure  should  be  kept  very 
clean  with  soap  and  warm  water ;  it  should  be  bathed  with  alcohol, 
thoroughly  dried,  and  well  dusted  with  powder  (starch  and  oxid  of 
zinc,  equal  parts) ;  and  the  pressure  should  be  relieved  by  proper 
pads  or  cushions.    If  the  heel  is  the  part  involved,  a  rubber  cushion 


FRACTURE  (IF  THK  HIP — TREATMENT  27 1 

or  a  ring  made  of  sheet  wadding  wound  with  a  bandage  mav  be 
used.  A  certain  amount  of  moving  about  in  bed  should  be  granted 
to  old  people.  Asthenic  hypostatic  pneumonia  from  long-con- 
tinued resting  in  one  position  is  not  uncommon.  Therefore,  mov- 
ing about  a  little  in  bed,  to  the  extent  of  sitting  upon  a  bed- 
rest at  varying  angles,  is  beneficial.  Deep  rhythmical  breathing 
while  lying  fiat  on  the  back  is  a  splendid  stimulator  of  the  circula- 
tion. In  the  case  of  a  fracture  of  the  neck  of  the  thigh-bone  occur- 
ring in  an  elderly  individual  treat  the  patient  and  let  the  fracture 
be  of  almost  secondary  importance. 

Treatment  of  the  Fractured  Hip. — The  patient  should  be  placed 
upon  a  comfortable,  firm,  hair  mattress.  Underneath  the  mat- 
tress, crossing  the  bedstead  from  side  to  side,  should  be  placed 
several  wooden  slats  about  eight  inches  apart.  These  bed-slats 
prevent  sagging  of  the  mattress  and  much  consequent  discomfort. 
Great  caution  must  be  exercised  that  no  sudden  or  forcible  move- 
ments of  the  hip  are  made  which  might  break  up  the  impaction  of 
the  bone  or  cause,  unnecessary  pain.  The  leg  should  be  placed  in 
as  natural  a  position  in  extension  as  possible.  The  knee  should  be 
placed  upon  a  pillow.  Extension  strips  of  adhesive  plaster  should 
be  applied  to  the  leg  and  thigh  as  high  as  the  perineum,  and  should 
be  held  to  the  skin  by  a  gauze  roller  bandage.  A  weight  of  about 
five  pounds  should  be  applied  to  the  extension  while  the  leg  is 
gently  rotated  and  carefully  placed  approximately  in  the  normal 
position.  The  foot  of  the  bed  should  be  elevated  to  the  height  of 
six  inches  in  order  to  secure  counterextension.  Long  and  heavy 
sand-bags  should  be  placed  on  each  side  of  the  leg  and  thigh  to 
assist  the  light  extension  in  afTording  support  and  to  give  a  sense 
of  security.  The  heel,  as  mentioned  before,  should  be  properly 
protected  from  undue  pressure.  The  foot  should  be  kept  at  a  right 
angle  with  the  leg.  To  afford  still  greater  immobilization,  a  long 
T-splint  extending  from  below  the  foot  to  the  axilla  of  the  injured 
side  may  be  applied  by  straps  about  the  leg  and  a  swathe  about  the 
body  (see  Fig.  410). 

After-care  of  the  vSimple  Traction  Method. — The  general  care 
of  the  patient  should  be  as  outlined  previously.  He  should  be  kept 
quiet  in  bed  for  about  two  weeks.  During  the  second  week  he 
may  be  bolstered  up  on  pillows  to  the  half-sitting  position.     Ordi- 


2  72  FRACTURES    OF    THE    FEMUR 

narily,  the  extension  may  be  removed  during  the  third  week.  The 
patient  may  then  be  lifted  to  another  bed  or  divan  and  be  rolled 
into  an  adjoining  room.  In  this  change  the  thigh  should  be  sup- 
ported by  sand-bags.  The  patient  may  be  up  in  a  wheel-chair  after 
the  first  six  weeks  or  two  months  with  the  knee  straight  on  a  board 
or,  if  comfortable,  flexed.  He  may  use  crutches  and  a  high  shoe 
upon  the  well  foot,  not  bearing  any  weight  upon  the  injured  hip, 
after  about  two  months  or  ten  weeks.  He  should  not  bear  weight 
upon  the  hip  even  with  the  assistance  of  crutches  for  about  three 
or  four  months.  At  the  end  of  a  }■  ear  he  may  be  walking  with  one 
cane.  The  foregoing  is  the  course  of  a  case  treated  accord- 
ing to  the  old-time  simple  extension  or  partial  immobilization 
method.  It  is  a  matter  of  common  observation  that  many  im- 
pacted hips  recover  with  fairly  useful  limbs  with  this  treatment. 
Impacted  hips  are  known  to  have  recovered  with  useful  limbs 
without  any  medical  or  surgical  advice  or  treatment,  the  impacted 
fracture  having  been  thought  at  the  time  of  the  injury  to  be  a  se- 
vere contusion  which  would  be  all  right  in  time.  These  cases  have 
occurred  both  among  adults  and  children. 

Greater  immobilization  of  the  impacted  and  unimpacted  hip  is 
demanded  in  most  cases  than  can  be  obtained  by  the  simple  trac- 
tion and  countertraction  previously  described.  The  simple  method 
is  far  from  ideal :  malunion  and  nonunion  with  resulting  disability 
too  often  follow  its  use,  the  period  of  disability  is  long,  and  the 
ultimate  results  are  often  most  unsatisfactory.  Very  refractory 
individuals  will  have  to  be  left  pretty  much  to  themselves.  No 
great  restraint  can  to  advantage  be  forced  upon  them. 

The  Fixation  Method  of  Treatment. — In  order  to  put  the  unim- 
pacted bones  of  the  hip-joint  under  the  very  best  conditions  for 
union  to  take  place  not  only  must  the  fragments  be  approximated 
by  traction,  correction  of  eversion  or  inversion,  and  lateral  pres- 
sure over  the  trochanter  major,  but  these  fragments  must  be  firmly 
fixed.  In  order  to  immobilize  these  fragments  absolutely  the 
body  or  pelvis  and  the  thigh  must  be  fixed.  The  simple  method 
already  described,  in  spite  of  the  fact  that  it  has  been  used  for 
many  3^ears  in  these  cases,  does  not  immobilize.  The  most  com- 
fortable and  efficient  method  of  immobilization  is  by  the  use  of  the 


FRACTURE    OF    Tlllv    HIP — TREATMENT 


273 


Thomas  hip-splint.  The  description  which  follows  of  the  Thomas 
hip-splint  and  its  use  is  that  given  by  Rid  Ion. 

The  Thomas  hip-splint  secures  posterior  support  to  the  fracture, 
gives  fixation  without  compression  of  the  fractured  region  except 
posteriorly,  allows  the  patient  to  be  lifted  with  ease,  does  not  inter- 
fere with  the  groin,  favors  cleanliness,  admits  of  traction,  can  be 
applied  without  moving  the  patient  and  without  assistance,  and 
presents  no  difficulties  after  the  initial  application  (see  Figs.  381, 
382). 

The  splint  is  made  of  soft  iron,  and  consists  of  a  main  stem,  a 


Fig.  381. — Thomas'   single   liip-spliiit    in 
position  (Ridlon). 


Fig.  382.— Tliomas'  double  hip-splint  in 
position  (Ridlon). 


chest-band,  a  thigh-band,  and  a  calf-band.  The  stem  is  an  inch 
and  a  quarter  wade  and  one-fourth  of  an  inch  thick,  and  in  length 
reaches  from  the  axilla  to  the  calf  of  the  leg— the  length  of  the 
lower  portion  from  the  hip-joint  to  the  calf  of  the  leg  being  equal 
to  that  from  the  axilla  to  the  hip-joint.  In  the  part  opposite  the 
buttock  tw^o  gentle  bends  are  made,  the  lower  somewhat  back- 
ward and  the  upper  upward,  so  that  the  body  and  leg  portions  of 
the  splint  follow  parallel  lines  from  one-half  to  one  inch  apart, 
the  body  portion  being  posterior  to  the  leg  portion.  The  stouter 
18 


2  74  FRACTURES    OF   THE    FEMUR 

the  patient,  the  more  nearly  do  these  parallel  lines  coincide,  and 
in  some  cases  the  main  stem  may  be  left  entirely  straight.  To 
the  lower  end  is  fastened,  by  one  rivet,  the  calf -band,  one-six- 
teenth by  five-eighths  of  an  inch,  and  in  length  an  inch  or  two 
less  than  the  circumference  of  the  leg  at  this  point.  The  thigh- 
band  is  one-sixteenth  bv  three-fourths  of  an  inch,  and  in  length  an 
inch  or  two  less  than  the  circumference  of  the  thigh  at  its  largest 
part;  it  is  riveted  to  the  main  stem  just  below  the  lower  bend,  so 
that  when  applied  to  the  patient,  it  comes  well  up  to  the  perineum. 
The  chest-band  is  three-thirty-seconds  by  one  and  one-fourth 
inches,  and  in  length  nearly  equal  to  the  circumference  of  the  chest, 
being  relatively  longer  than  the  other  bands.  It  is  fastened  by 
one  rivet  after  the  upper  end  of  the  stem  has  been  forged  flat  and 
bent  back  over  it.  This  arrangement  makes  a  fast  joint,  and 
brings  the  stem  between  the  chest-band  and  the  skin.  In  each 
end  of  the  chest-band  a  round  hole  is  forged  of  at  least  one-half  of 
an  inch  in  diameter. 

Summary  of  material  and  measurements  required  in  making 
the  Thomas  splint : 

Stem,  i\  inches  wide,  ^  inch  thick,  extending  from  the  axilla  to 
the  calf  of  the  leg. 

Calf -band,  f  inch  wide,  j-^  inch  thick ;  the  length  is  two  inches 
less  than  the  circumference  of  the  calf  of  the  leg. 

Thigh-band,  f  inch  wide,  -j^  inch  thick;  the  length  is  two  inches 
less  than  the  largest  circumference  of  the  thigh. 

Chest-band,  ij  inches  wide,  ^^2"^'^cli  thick;  the  length  to  nearly 
equal  the  circumference  of  the  chest. 

A  hole  is  forged  at  each  end  of  the  chest-band,  ^  inch  in  diam- 
eter. Any  good  blacksmith  can  make  this  splint  in  a  very  short 
time. 

The  splint  is  now  bent  to  fit  approximately  the  patient,  padded 
on  the  side  that  is  to  come  next  the  skin  with  a  quarter-inch  thick- 
ness of  felt,  care  being  taken  to  leave  no  inequalities  of  surface, 
and  then  covered  with  basil  leather  put  on  wet  and  tightly  drawn, 
so  that  when  dry  it  will  have  shrunk  sufficiently  to  prevent  the 
cover  from  slipping  on  the  iron.  The  splint  is  applied  by  opening 
out  the  wings  of  the  bands  looking  to  the  uninjured  side  of  the 
patient,  and  then  slipping  them,  followed  by  the  stem,  und?r- 


FRACTrKIv    OF    THK    HIP  —  TKRATMKNT  275 

neath  lla-  iJatie-iU  I'nmi  the  injured  side;  the  wings  that  were 
straightened  are  bent  again  b\'  hand  and  readily  return  to  their 
former  curves.  A  closer  and  more  accurate  adjustment  of  the 
wings  may  be  made  by  the  use  of  wrenches;  these  will  be  found 
especially  serviceable  in  fitting  the  chest-band  and  in  drawing  in 
the  other  bands  when  the  patient  is  very  intolerant  of  any  threat- 
ened movement  or  jarring. 

"The  splint  having  been  fitted,  if  retentive  traction  is  not  re- 
quired, the  limb  is  bandaged  to  the  stem  from  the  calf  to  the  upper 
part  of  the  thigh,  rolling  the  bandage  in  the  direction  the  opposite 
to  the  rotary  deformity  that  may  be  present ;  then  shoulder-straps 
are  applied  by  taking  a  couple  of  yards  of  broad  bandage  or  a  strip 
of  muslin,  looping  it  round  the  stem  where  it  joins  the  chest-band, 
then  over  the  band  and  over  the  shoulders,  and  down  to  the  ends 
of  the  chest-band.  Here  it  is  passed  through  the  holes  and  tied ; 
then  it  is  passed  across  the  intervening  space  to  the  opposite  hole 
and  again  tied.  If  retentive  traction  is  desired,  the  shoulder- 
straps  are  omitted.  To  each  side  of  the  limb  from  the  upper  part 
of  the  thigh  after  the  limb  has  been  pulled  down  to  the  splint  a 
broad  strip  of  adhesive  plaster  is  applied.  The  lower  ends  of  the 
plaster  are  turned  outward  and  upward  around  the  wings  of  the 
calf-band,  where  they  are  fastened  by  a  strip  of  plaster  passed 
entirely  around  the  limb ;  the  whole  is  then  covered  with  a  band- 
age. By  this  arrangement  the  limb  is  pulled  upon  only  to  the 
extent  of  correcting  the  actual  shortening,  and  is  held  at  one  and 
the  same  length  sleeping  or  w^aking,  whether  the  muscles  relapse 
or  are  spasmodically  contracted. 

"The  device  aims  to  prevent  motion  in  the  axis  of  the  limb ;  to 
prevent  lateral  motion  by  bending  the  limb  in  any  direction;  to 
do  this  without  constricting  the  region  of  the  fracture;  and  to 
enable  the  patient  to  have  the  bed-pan  adjusted  without  pain  and 
without  disturbing  the  relation  of  the  parts.  When  the  splint 
has  been  applied  and  the  patient  is  in  bed,  the  nurse  should  be 
instructed  in  certain  mana^uvers.  The  bed-pan  is  adjusted  by 
passing  the  arm  under  both  limbs  or  below  the  knees  and  then 
lifting  directly  upward,  making  an  incline  of  the  W'hole  patient 
below  the  chest-band.  By  this  manoeuver  it  is  also  more  easy 
to  sraoothe  out  wrinkles  in  the  bedding:  and  change  the  sheet  than 


276  FRACTURES   OF   THE   P'EMUR 

in  the  usual  way.  The  stem  should  be  made  to  press  upon  differ- 
ent parts  of  the  skin  by  pulling  the  skin  night  and  morning  first 
to  one  side  and  then  to  the  other.  The  patient  should  be  inspected 
daily  for  pressure  sores  by  turning  him  on  the  sound  side.  In 
order  to  turn  a  patient  upon  the  sound  side  support  the  fractured 
limb  at  the  knee  with  one  hand  and  grasp  the  chest-band  with  the 
other;  the  patient  then  is  readily  turned  as  a  whole.     The  points 


Fig.  383.— Tracing  of  photograph  of  patient  (see  skiagram,  Fig.  3S4)  four  years  after 
fracture  of  the  left  femoral  neck,  showing  the  shortening  and  turning  out  of  the  leg  (after 
Whitman). 


most  likely  to  suffer  from  pressure  are  those  at  the  junction  of  the 
thigh-band  and  stem,  the  lower  bend  of  the  stem,  and  the  junction 
of  the  stem  and  chest-band.  Points  pressed  upon  should  be  lightly 
dressed  with  flexible  collodion  and  protected  from  further  pressure 
by  padding  above  and  below.  If  the  pressure  of  the  whole  body 
portion  of  the  stem  is  complained  of,  a  small,  thin  mattress  of  hair 
or  a  sheet  folded  to  several  thicknesses  may  be  placed  between  the 


FRACTIRK  ()I-  THK  HIP — TREATMENT  277 

splint  and  the  patient's  back.  Threatened  h>'postatic  congestion 
is  obviated  by  raising  the  head  of  the  bed  from  one  to  three  feet, 
the  patient  meanwhile  being  prevented  from  slipping  down  by 
tying  the  splint  to  the  head  of  the  bed.  In  all  cases  obviouslv  un- 
impacted  and  in  all  cases  when  the  shortening  is  more  than  three- 
fourths  of  an  inch,  traction  should  be  applied. 

"In  all  cases  the  splint  should  be  kept  on  for  from  six  to  eight 
weeks  after  all  pain  has  ceased ;  then  the  patient  should  remain 
in  bed  four  weeks  longer  without  any  treatment  whatever,  unless 
there  is  some  positive  indication  to  the  contrary,  in  which  case  the 
splint  is  cut  off  at  the  knee  and  the  calf-band  riveted  at  this  point 
and  the  patient  permitted  to  go  about  with  crutches." 


Fig.  3S4. — Skiagram  tracing  of  patient  two  and  a  half  years  of  age,  after  the  accident, 
illustrating  the  deformity  of  the  neck  and  of  the  upper  extremity  of  the  shaft,  also  the  eleva- 
tion of  the  pelvis  on  the  affected  side  (after  Whitman). 


In  addition  to  the  use  of  the  Thomas  splint,  it  may  be  wise  to 
make  lateral  pressure,  as  suggested  by  Senn,  over  the  trochanter 
of  the  broken  hip  with  the  expectation  of  more  firmly  fixing  the 
broken  bone.  Lateral  pressure  may  be  secured  by  a  surcingle  or 
by  a  bandage  applied  over  a  graduated  compress.  The  spot  to 
which  pressure  is  applied  should  be  carefully  watched  and 
protected. 

The  Operative  Treatment. — Suturing  or  pegging  the  fragment 
is  very  properly  to  be  reserved  for  fractures  occurring  in  voung 
adults  in  whom  the  absolute  fixation  by  the  Thomas  splint  for  a 
reasonable  period  has  not  effected  union. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood.— Whitman 


278 


FRACTURES   OF   THE   FEMUR 


has  called  especial  attention  to  this  fracture.  The  anatomical 
proof  of  the  existence  of  fracture  of  the  neck  of  the  femur  in  child- 
hood has  been  furnished  by  the  specimens  of  Bolton,  Meyers,  and 
Starr.  The  fracture  occurs  after  traumatism  to  the  hip  probably 
more  frequently  than  separation  of  the  upper  femoral  epiphysis. 


Fig.  385. — Tracing  of  pliotograpli  of  patient  eiglit  years  old,  some  years  after  a  fracture 
of  the  neck  of  tlie  right  femur,  showing  great  projection  and  elevation  of  the  trochanter, 
made  more  apparent  by  flexing  the  thigh  and  leg  (Whitman). 


It  is  not  SO  uncommon  an  accident  as  has  been  supposed.  The 
fracture  is  probably  impacted  or  greenstick.  The  clinical  picture  of 
fracture  of  the  neck  of  the  femur  in  childhood  differs  greatly  from 
that  furnished  by  a  similar  injury  in  old  age.  In  the  first  instance 
a  healthy  child  falls  from  a  height,  and  presents  a  shortening  of 
the  thigh  of  from  one-half  to  three-quarters  of  an  inch.     There 


Head  of  fcimir. 


Marks  iipi)er  limit  of  head  of  bone. 


Shaft  of 

femur, 

lower 

fragment. 


Fig.  386.- 


-Case  :  Girl  13  years  of  age.     Old  fracture  of  shaft  of  femur  with  vicious  union. 
Fresh  fracture  of  neck  of  femur. 


279 


2 So  FRACTURES    OF    THE    FEMUR 

are  slight  outward  rotation  of  the  leg  and  limitation  of  motion  and 
slight  discomfort  in  the  hip.  The  child  may  walk  about  after  a 
few  days  with  but  a  little  lameness  to  suggest  that  any  injury  has 
been  received.  The  child  recovers  with  a  limp.  Months  or  years 
later  signs  of  coxa  vara  appear.  In  childhood  a  rather  severe 
injury  is  followed  by  immediate  symptoms,  and  later  by  great  dis- 
ability. On  the  other  hand,  in  old  age  a  trivial  injury  is  followed 
by  immediate  and  complete  disability.  It  is  often  overlooked 
in  the  child  and  is  treated  for  a  contusion  or  sprain  of  the  hip. 
The  immediate  result,  however,  is  extremely  good  even  without 
more  than  bed  treatment,  but  the  ultimate  result  after  several 
months  or  years  may  be  disastrous  because  of  the  disability  due 
to  a  gradually  increasing  bending  of  the  femoral  neck.  The  late 
result  of  fracture  of  the  femoral  neck  in  childhood  resembles  hip- 
disease  in  the  limp,  slight  pain,  shortening,  deformity,  and  limita- 
tion of  motion  present.  Care  must  be  taken  not  to  confound  the 
cw^o  conditions.  These  later  stages  of  fracture  are  to  be  treated  by 
rest  to  the  joint.  All  body-weight  and  the  jar  of  walking  are  to  be 
removed  by  a  properly  fitting  hip-splint  with  traction.  Refrac- 
ture  and  operative  measures  are  to  be  serioush^  entertained,  as  in 
other  forms  of  coxa  vara,  particularly  if  the  disability  is  great  or  is 
increasing  (see  Figs.  385-390  inclusive). 

The  treatment  of  a  fresh  greenstick  or  impacted  fracture  of  the 
hip  in  children  should  be  by  rest  on  the  back  in  bed  and  moderate 
traction  and  immobilization  of  the  hip  and  thigh  and  body.  After 
a  month  the  child  may  be  allowed  up,  wearing  a  traction  hip-splint 
for  several  months  until  union  is  so  firm  that  the  danger  from  coxa 
vara  is  practically  eliminated.  A  light  plaster-of-Paris  spica 
bandage  from  calf  to  axilla  will  maintain  immobility  after  the 
splint  is  omitted. 

FRACTURE  OF  THE  SHAFT  OF  THE  FEMUR 
Fracture  of  the  shaft  of  the  femur  is  usually  oblique.  It  is 
situated  either  just  below  the  lesser  trochanter  (subtrochanteric 
fracture),  at  the  center  of  the  shaft,  or  above  the  condyles  (supra- 
condyloid  fracture).  Even  in  closed  fractures  there  is  sometimes 
great  damage  to  the  soft  parts :  the  vessels  of  the  thigh  are  at  times 
injured. 


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281 


2  82  FRACTURES    OF    THE   FEMUR 

Symptoms. — There  is  often  great  swelling  at  the  seat  of  frac- 
ture. The  limb  lies  helpless.  Pain,  abnormal  mobility,  deform- 
ity, marked  lateral  rolling  of  the  leg  below  the  seat  of  the  fracture, 
and  crepitus,  one  or  all,  may  be  evident  (see  Figs.  391,  392).  The 
limb  is  shortened. 

Measurement  (see  Figs.  395-398  inclusive)  to  determine  the 
amount  of  the  shortening  is  to  be  made  from  the  anterior  superior 
spinous  process  of  the  ilium  to  the  internal  malleolus  of  the  same 
side.  Great  care  must  be  exercised  in  taking  this  measurement 
so  that  the  patient  lies  flat  upon  the  back  upon  a  hard  and  even 
surface,  with  the  arms  at  the  sides  of  the  body  and  with  no  pillow 
under  the  head  or  shoulders.     The  long  axis  of  the  body  should 


Fig.  391.— Fracture  of  the  thigh  at  the  middle.     Characteristic  deformity. 

be  in  the  same  line  with  the  long  axis  between  the  legs  as  they 
lie  with  the  malleoli  approximated — i.  e.,  the  chin,  episternal 
notch,  umbilicus,  the  symphysis  pubis,  the  midpoint  between  the 
knees,  and  the  midpoint  between  the  internal  malleoli  should  all 
be  in  one  straight  line  (see  Fig.  398).  The  line  joining  the  ante- 
rior superior  spinous  processes  of  the  ilia  should  be  at  right  angles 
to  this  long  axis  of  the  body  and  thighs.  Any  variations  from  this 
normal  position  are  attended  by  errors  in  measurement,  which 
are  important.  If  for  any  reason  the  injured  thigh  can  not 
be  brought  easily  alongside  its  fellow,  the  two  limbs  should  be 
placed  as  nearly  symmetrical  with  reference  to  the  median  line 
as  possible. 


THE    SHAFT    OF    THE    FEMIR 


283 


The-  iiK'thod  of  measuring  the  lengths  of  the  lower  extremities 
used  by  Dr.  Keen  differs  from  the  above  in  that  he  uses  the  malleo- 
lus as  the  fixed  point,  and  measures  to  a  line  drawn  at  the  anterior 
superior  spinous  process  of  the  ilium.  The  finger  and  tape  are  not 
allowed  to  touch  the  skin-mark,  and  so  do  not  displace  it. 

Treatment  of  Fracture  of  the  Shaft  of  the  Femur. — The  Trans- 
portation of  a  Patient :  The  emergency  method  of  putting  up  a 
fracture  of  the  thigh  or  hip  is  of  very  great  practical  importance 
(see  Fig.  399).  Limbs  are  fractured  frequently  some  distance 
from  the  proper  place  for  the  application  of  the  permanent  dress- 
ing.    It  is  necessary  to  transport  such  cases  with  the  greatest  de- 


Fig.  392. — Fracture  of  the  right  femur  at  the  middle.     Characteristic  deformity.     Inward 
rotation  of  leg  below  fracture. 


gree  of  safety  and  comfort.  In  order  to  accomplish  this  the  knee- 
and  hip- joints  should  be  extended,  the  leg  being  held  straightened 
in  the  long  axis  of  the  body.  The  limb  should  be  placed  upon  a 
heavily  padded  board,  the  width  of  the  thigh,  extending  from  the 
middle  of  the  calf  to  above  the  sacrum.  The  side  splints  of  wood 
should  be  used — one  on  the  outer  side  extending  from  the  side  of 
the  foot  to  the  axilla,  the  other  upon  the  inner  side  extending  from 
the  side  of  the  foot  to  a  few  inches  below  the  perineum.  Upon  the 
front  of  the  thigh  is  placed  a  coaptation  splint  extending  from  the 
groin  to  the  patella.  All  of  these  splints  are  carefully  padded,  pref- 
erably with  folded  sheets  or  pillow-cases  or  towels ;  of  course,  in 


^'S-  393- — Fracture  of  the  upper  third  of  the  shaft  of  the  right  femur  (X-ray  tracing 


Fig.  394. — Long  oblique  fracture  of  the  shaft  of  the  femur  (Massachusetts  General  Hospital, 

1250.     X-ray  tracing). 
284 


THE    SIIAKT    OF    THIv    I'UMIR 


285 


emergency  wt)rk  small  jjillows  or  coats  or  shawls  mav  be  utilized. 
It  is  important  that  the  padding  be  evenly  and  intelligently  ar- 
ranged. It  will  be  necessary  to  place  a  wide  pad  between  the 
upper  end  of  the  long  outside  splint,  to  prevent  it  from  pressing 
upon  the  ribs  and  side  of  the  chest  and  causing  great  discomfort. 
These  splints  are  held  in  position  about  the  le.s;-,  while  gentle  trac- 


Fis-  395- — Fracture  of  the  thigh.     Correct  method  of  measurement  from  the  anterior  superior 
spinous  process  of  the  ilium.    Position  of  thumb  and  finger  holding  tape. 


isuiemeiu  ot 


over  L-xtrciiiil_\  .     fositioii  ul    ihumi/.s 
limb. 


Xoie  position  of 


tion  is  being  made  upon  the  limb,  by  straps  or  pieces  of  bandage 
placed  above  the  ankle,  below  the  knee,  above  the  knee,  at  the 
middle  of  the  thigh,  and  at  the  level  of  the  perineum.  The  upper 
end  of  the  long  outside  splint  is  held  to  the  side  by  a  swathe  about 
the  body  and  splint.  The  patient  should  then  be  carefully  placed 
upon  a  stretcher  (a  Bradford  frame  is  an  ideal  form  of  stretcher) 


2  86  FRACTURES    OF    THE   FEMUR 

improvised  for  the  occasion.     With  this  apparatus  snugly  appHed, 
the  patient  may  be  securely  and  comfortably  transported. 

The  objects  of  treatment  are  to  reduce  the  fracture,  to  maintain 
the  reduction  immobilized  until  union  is  firm,  and  to  restore  the 
leg  to  its  normal  usefulness.  In  the  treatment  of  two  of  the  three 
varieties  of  fracture  of  the  femur  permanent  traction  upon  the 
lower  fragment  and  permanent  countertracticn  upon  the  upper 
fragment  are  necessarv. 


Fig.  397. — Measurement  of  lower  extremity.     Patient  lying  on  the  back  looked  at  from  above. 
Position  of  tape,  hands,  and  limb  to  be  noted. 


The  patient  with  a  fractured  thigh  should  always  be  anesthe- 
tized before  putting  the  thigh  up  permanently.  Never  anesthetize 
the  patient  until  all  the  different  parts  of  the  apparatus  are  ready 
and  on  a  table  near  the  bed  of  the  patient.  Always  put  the  thigh 
up  in  temporary  dressings  until  all  is  prepared  for  the  permanent 
splints.  About  one  hour  will  be  consumed  in  applying  the  exten- 
sion apparatus  after  the  patient  is  anesthetized.  There  will  be  no 
harm  in  letting  the  patient  rest  comfortably  in  the  temporary 


TIIK    SHAFT    OF    THE    FE.MIR 


28: 


splints  over  one  night  until  all  necessary  arrangements  have  been 
made  for  the  permanent  dressing. 

Method  of  Examination :  The  patient  is  completely  anesthetized 
in  t)rder  to  secure  muscular  relaxation.     Accurate  examination  is 


F'g-  398.— Measurement  of  the  length  of  the  lower  extremity.  Patient  represented  lying 
on  back,  looked  at  from  above.  The  line  joining  the  anterior  superior  spinous  processes  of 
ilia  (C,  D)  should  be  at  right  angles  to  the  long  axis  of  the  body  (^,  B).  In  this  position  only 
can  comparable  measurements  be  made.     (Drawn  by  C.  Rimmer.) 


now  made  of  the  fracture.  If  the  ends  of  the  fragments  lie  close  to 
the  skin,  great  care  must  be  exercised,  by  steadying  the  thigh,  to 
prevent  them  being  pushed  through  the  skin  and  thus  rendering 
the  fracture  an  open  one.     An  assistant  should  steady  the  pelvis 


288  FRACTURES    OF    THE    FEMUR 

and  upper  thigh  (see  Fig.  400).  The  surgeon  should  grasp  the 
thigh  above  the  condyles  with  both  hands,  and  should  make  trac- 
tion in  the  axis  of  the  limb.  He  then  determines  the  pull  neces- 
sary to  be  exerted  to  hold  the  fragments  reduced.  While  this  pull 
is  maintained  by  an  assistant,  the  surgeon  manipulates  the  thigh 
in  order  to  learn  with  what  ease  or  difficulty  the  fragments  may  be 
held  in  position. 

In  adults  in  fracture  of  the  middle  of  the  shaft  of  the  femur  trac- 
tion and  immobilization  are  best  maintained  by  a  modified  Buck's 


Fig-  399- — Fracture  of  hip  or  thigh.     Emergency  apparatus. 


Fig.  400. — Fracture  of  the  thigh.     Method  of  holding  leg  in  order  to  detect  fracture  of  the 
thigh.     Pelvis  is  steadied  by  an  assistant. 


extension  apparatus.  Materials  needed  for  a  modified  Buck's  ex- 
tension :  Two  strips  of  adhesive  plaster,  each  two  inches  wide  and 
long  enough  to  extend  from  the  seat  of  fracture  to  the  internal 
malleolus.  Surgeon's  adhesive  plaster  is  nonirritating  to  the  skin, 
and  is  prepared  in  rolls  of  convenient  width.  To  each  strip  of 
plaster  at  the  ankle  end  should  be  stitched  a  piece  of  webbing  the 
width  of  the  plaster  and  about  six  inches  long.  Prepare  five  other 
strips  of  adhesive  plaster,  all  of  which  should  be  one  and  a  half 
inches  wide.     Three  of  these  strips  should  be  long  enough  to  encir- 


THE   SHAFT   OF   THE   FEMUR 


!89 


cle  respectively  the  leg  above  the  malleoh,  the  knee  above  the  con- 
dyles, and  the  thigh  an  inch  below  the  seat  of  the  fracture.  The 
remaining  two  strips  of  plaster  should  be  long  enough  to  extend 
spirally  from  the  malleoli  around  the  leg  and  thigh  to  the  scat  of 
fracture.  Prepare  also  a  roller  bandage  of  gauze  or  cotton  cloth, 
a  curved  or  straight  ham-splint  properly  padded,  and  three  adhe- 
sive straps  for  holding  the  ham-splint. 

In  addition,  three  coaptation  splints  for  surrounding  the  thigh 
are  required,  also  six  webbing  straps  with  buckles  or  strips  of  band- 
age to  be  used  as  straps ;  fresh  sheets  or  pillow-cases  or  towels  for 


Fig.  401.— Pulley  arranged  on  broom-handle  to  be  fastened  at  foot  of  bed  for  carrying  exten- 
sion cord. 


padding;  a  swathe,  to  encircle  the  pelvis,  made  of  unbleached 
cotton  cloth  or  medium  weight  Shaker  flannel ;  and  a  long  outside 
splint  of  wood,  four  inches  wide,  to  extend  from  the  axilla  to  six 
inches  below  the  sole  of  the  foot.  To  this  last  a  cross-piece,  eigh- 
teen inches  long,  should  be  fastened,  making  thus  a  long  T-spHnt. 
The  list  is  completed  by  two  towels  for  perineal  straps,  safety-pins, 
a  pulley,  which  can  be  bought  at  little  cost  at  any  hardware  store 
(see  Fig.  401).  This  pulley  should  be  screwed  into  a  broom-han- 
dle cut  to  the  right  height .  A  block  with  hooks  above  and  a  pulley 
below  will  sometimes  be  found  to  be  more  convenient  than  the 
19 


290 


Till-:    SHAFT    oK    THi:    l-IvMUR 


291 


broom  haiulk'  arraiii^a-iiK-nt  (sec  Imr-  403).  A  spreader  (see  Fig. 
404),  whicli  is  a  piece  of  wood  two  inches  wide  aiul  a  little  longer 
than  the  width  of  the  foot,  perforated  at  its  center  for  the  exten- 
sion weight  cord.  There  should  be  provided  a  cord,  three  feet 
long,  size  of  a  clothes-line;  two  bricks  or  wooden  blocks  for  ele- 
vating the  foot  of  the  bed  ;  four  siuulhac/s,  twenty  inches  long  and 
six  inches  wide ;  a  cradle  (see  h'igs.  405,  406J  to  keep  the  weight  of 
the  clothes  from  the  thigh — the  cradle  may  be  a  chair  tipped  up, 
or  barrel-hoops  nailed  together. 

Application  0}  the  Modified  Buck's  Extension. — All  the  materials 
being  in  readiness  and  at  hand,  the  patient  having  been  etherized 
and  the  fracture  examined,  the  thigh  and  leg  and  foot  are  first 


Fig.  403. — Pulley  arranged  for  bed. 


washed  with  warm  water  and  Castile  soap  and  thoroughly  dried. 
The  long  straight  strips  of  adhesive  plaster  with  the  webbing 
attached  are  applied  to  the  middle  of  the  two  sides  of  the  leg  and 
thigh  up  to  the  seat  of  fracture.  The  junction  of  the  adhesive 
plaster  and  webbing  should  be  brought  to  just  above  the  malleoli. 
The  two  spiral  and  then  the  three  circular  strips  should  next  be 
applied  as  indicated  (see  Fig.  407).  Over  the  extension  is  placed 
a  roller  bandage,  snugly  and  evenly  inclosing  the  foot.  The 
bandage  steadies  the  adhesive  plaster,  prevents  swelling  of  the  foot, 
and  affords  comfort.  Then  the  padded  posterior  coaptation  or 
ham-splint  is  applied  and  held  by  three  straps  of  adhesive  plaster, 
one  at  each  end  of  the  splint  and  one  below  the  knee  (see  Fig.  408). 
If  the  curved  ham-splint  is  used,  the  padding  (one  sheet  of  sheet 


292 


FRACTURES    OP   THE   FEMUR 


wadding)  should  be  laid  upon  the  splint  evenly  throughout.  If  a 
straight  ham-splint  is  used,  the  padding  should  be  applied  evenly, 
and  at  the  middle  of  the  ham,  behind  the  knee,  should  be  placed  an 
additional  pad  (see  Fig.  409)  in  order  to  support  the  knee  in  its 
natural  position.  This  additional  pad  should  be  placed  between 
the  splint  and  the  layer  of  sheet  wadding.  The  tendency  of  the 
padding  of  the  ham-splint  is  to  slip  away  from  each  end  of  the 
splint  and  thus  leave  it  unduly  pressing  into  the  thigh  and  calf.  It 
is  wise  to  hold  this  padding  in  place  by  strips  of  adhesive  plaster  at 


Fig.  404. — Spreader  of  wood  for  preventing  extension  straps  from  chafing  ankle  and  foot. 
Cord  for  attaching  weight. 


each  end  of  the  splint.  The  three  thigh  coaptation  splints  should 
be  next  put  in  position — one  anteriorly,  extending  the  whole  length 
of  the  thigh  from  groin  to  patella ;  one  externally,  extending  from 
trochanter  to  external  condyle;  and  one  internally,  extending 
from  just  below  the  perineum  to  just  above  the  adductor  tubercle 
(see  Fig.  409).  The  best  padding  for  these  splints  is  a  towel  folded 
the  length  of  the  splints  and  placed  eventy  about  the  thigh.  These 
splints  are  held  by  an  assistant  while  three  or  four  straps  are  tight- 
ened sufficiently  to  hold  them  firmly  in  place.  While  these  coap- 
tation splints  are  being  applied  it  is  vers-  important  that  steady 


THK    SHAFT    oF    THE-:    FEMUR 


293 


traction  be  made  iipnii  llu-  lower  fraj,Miic-iit  in  order  to  maintain  its 
reduction.  The  straps  of  the  coai)tation  sphnts  are  then  finally 
tightened.  The  long  outside  splint  with  the  T  cross-piece  is  then 
padded  with  sheets  and  applied  to  the  side  of  the  limb  and  the 
body  (see  Fig.  410).  The  upper  end  of  the  splint  is  inclosed  in  a 
swathe,  which  passes  around  the  body  and  is  fastened  with  safety- 
pins.     The  thigh  and  leg  are  held  steadily  to  the  outside  sphnt  by 


Fig.  405.— Cradle  to  keep  clothes  from  leg.     Made  from  two  barrel-hoops. 


Fig.  406.— Cradle  to  keep  clothes  from  leg.     Made  from  two  barrel-hoops. 


two  or  three  straps  (see  Fig.  411).  The  assistant,  making  exten- 
sion, exchanges  his  traction  for  that  of  the  weight  and  pulley.  The 
foot  of  the  bed  is  raised  upon  blocks  or  bricks,  in  order  to  provide 
the  counterextension  by  means  of  the  weight  of  the  body.  The 
heel  is  protected  from  undue  pressure  by  a  ring.  The  foot  is  kept 
at  a  right  angle  with  the  leg  (see  Figs.  412,  413).  The  sand-bags 
are  laid  along  the  inner  and  outer  sides  of  the  limb  to  add  greater 


Fig.  407. — Fracture  of  the  thigh.     Adhesive-plaster  exttnsion  strips ;  long  upright,  ciicular, 
and  obliquely  applied  strips. 


Fig.  408. — Fracture  of  the  thigh.     Extension  strips  applied ,  covered  by  bandage.     Ham-splint 
applied  ;  tvi^o  straps  and  pad  in  ham. 


Fig.  409. — Fracture  of  the  thigh.     Extension  strips  applied.     Cotton  bandage.     Ham-splint, 
straps,  pad,  and  coaptation  splints  about  the  seat  of  fracture.     Straps  and  buckles. 

294 


Till-    SHAFT    (I I"    Tin-:    rHMl'R 


295 


steadiness  to  the  apparatus.     The  cradle  is  placed  over  the  foot 
and  le.!,^ 

ThrouglioLiL  the  course  oi  the  treatment  of  a  fracture  of  the 
thigh  it  is  necessary  to  be  positive  of  four  things :  (a)  The  absence 
of  shortening  in  the  injured  thigh;  (b)  the  prevention  of  outward 
bowing  of  the  thigh ;  (c)  the  prevention  of  permanent  rotation  of 
the  leg  and  lower  thigh  outward  below  the  seat  of  fracture;  and 


Fig.  410. — Fracture  of  the  thigh.    Completed  apparatus  as  in  figure  409,  and  in  addition  a  long 
outside  T-splint,  straps,  and  swathe.     Weights  applied. 


Fig.  411.— Fracture  of  the   thigh.     Completed   apparatus  with   bed   elevated.     Tlie   outside 
splint  is  broad  and  without  the  T  foot-piece.    The  swathe  is  very  snugly  applied. 


finally  (d),  the  prevention  of  a  sagging  backward  of  the  thigh  at 
the  seat  of  fracture,  causing  what  appears  on  standing  as  a  false 
genu  recur\'atum. 

(a)  The  shortening  of  the  injured  leg  is  prevented  by  a  suf- 
ficiently heavy  weight  for  extension.  This  weight  can  be  approxi- 
matelv  but  not  accurately  determined.  Ordinarily,  in  an  adult 
fifteen  or  twenty  pounds  are  needed  to  hold  the  fragments  in 
proper  position.     Comparative  measurement  of  the  legs  from  the 


Fig.  412.  Fig.  413. 

Figs.  412,  413. — Forms  of  stirrup  to  prevent  the  foot  assuming  an  equinus  position. 


Fis 


414. — Diagram  of  section  of  leg  and  splint  to  show  how  a  strap  carried  from  the  back 
of  the  leg  over  the  long  side-splint  can  prevent  eversion  of  the  foot  and  leg. 


Fig.  415. — The  more  usual  deformities  in  fracture  of  the  shaft  of  the  femur.     Outward  and 

posterior  bowing. 
296 


THU  SHAFT  OK  THK  FEMUR 


297 


anterior  superior  spinous  process  to  the  malleolus  should  be  made' 
regularly  ever\'  other  day,  and  the  measurements  recorded  during 
the  first  two  weeks  of  immobilization  and  the  extension  weight 
correspondingly  adjusted. 

(b)   In  order  to  prevent  an\"  outward  bowing  of  the  thigh,  the 


v..: 


Fig.  416. — Showing  the  necessity  of  abducting  the  injured  leg  in  thigh  fracture.     In  dotted 
line  is  shown  the  position  likely  to  result  from  neglect  of  this  abduction. 


thigh  and  leg  should  be  slightly  abducted  after  the  apparatus  is 
applied,  so  that  the  extension  is  made  with  the  limb  in  this  ab- 
ducted position  (see  Fig.  416). 

(c)  In  order  to  prevent  the  thigh  from  rotating  outward  below 
the  fracture  and  thus  carrying  the  leg  and  foot  with  it, — to  pre- 
vent, in  other  words,  eversion  of  the  foot, — a  bandage  six  inches 


298  FRACTURES    OF    THE    FEMUR 

wide  should  be  fastened  by  pins  below  the  calf  of  the  leg  to  the 
posterior  part  of  the  bandage  or  ham-splint,  and  brought  up  on 
the  outer  side  of  the  leg  and  fastened  to  the  long  outside  splint  or 
to  the  cradle  above.     The  leg  meanwhile  is  held  in  the  corrected 


Fig.  417. — Action  of  the  muscular 
pull  of  the  iliopsoas  and  of  the  external 
rotators  in  producing  deformity  in  frac- 
ture of  the  femur  high  up.  Upper  frag- 
ment is  flexed  and  abducted  upon  the 
trunk. 


Fig.  418. — Case;  Oblique  subtrochanteric  fracture 
of  shaft  of  lemur  (X-ray  tracing). 


position.     If  this  bandage  is  fastened  to  the  cradle,   the  latter 
should  be  fastened  firmly  to  the  bed. 

(d)  The  sagging  backward  of  the  thigh  (see  Fig.  415)  is  pre- 
vented by  the  posterior  coaptation  splint  and  its  proper  padding. 
(See  Supra  condyloid  Fracture  of  the  Femur.) 


SrHTK(»Cll.\NTi:KIC    rKACTtki: 


299 


Subtrochanteric  Fracture  of  the  Shaft  of  the  Femur. — I'rac- 
tures  of  the  ui)])rr  third  nl'  the  shaft  an-  c()nii)arati\c'l\-  rare.  The 
diagnc^is  oi  this  fracture  is  not  ordinarily  dinicult.  The  dispkice- 
nient  is  characteristic  :  The  upper  fragment  is  Hexed  and  abducted, 
and  the  lower  fragment  overrides  the  upper  one  and  is  shghtl}- 
adducted.  The  treatment  should  restore  the  line  of  the  thigh. 
At  times  the  ordinary  extension  and  counterextension,  as  for  a 
fracture  of  the  middle  of  the  femur,  may  prove  effective.     If  it  is 


Fi.£ 


419. — Spiral  fracture  of  the  shaft  of  the 
femur  high  up  (X-ray  tracing). 


Fig.  420. — Spiral  fracture  of  the  upper 
half  of  the  femur.  View  from  in  front  and 
externally  (Warren  Museum,  specimen 
1103). 


not  effective, — and  it  usually  is  not, — the  leg  and  lower  fragment 
should  be  elevated  upon  an  inclined  plane  (see  Fig.  434),  so  as  to 
bring  the  lower  fragment  up  to  the  upper  one,  for  it  will  be  found 
impossible  to  lower  the  upper  fragment.  Traction  should  then  be 
made  in  the  line  of  the  elevated  thigh  from  above  the  condyles  of 
the  femur.  If  position  and  traction  are  inefficient, — and  they 
usually  are, — then  suturing  of  the  fragments  should  be  contem- 
plated. 

It  will  be  found  impossible  to  correct  completely  the  ordinary 


300 


FRACTURES    OF    THE    FEMUR 


deformity  of  abduction  and  flexion  of  the  upper  fragment  and  ad- 
duction and  riding  up  of  the  lower  fragment  by  traction  upon  the 
lower  fragment,  no  matter  in  what  position  the  lower  fragment 
may  be  placed  for  traction.  Rendering  the  closed  fracture  open 
by  incision  and  suturing  the  bones  in  position  is  the  onlv  possible 
wa}'  of  securing  a  perfect  result  either  anatomically  or  functionally. 
The  surgeon  must  be  judicious  in  the  selection  of  the  patients  upon 
whom  he  operates.     Even  though  old,  if  the  patient  is  in  excellent 


Fig.  421. — Same  speci- 
men as  figure  420,  from  be- 
hind. 


Fig.  422.  —  Fractured 
femur,  base  of  neck  driven 
into  the  shaft.  Spiral  frac- 
ture of  shaft  just  below  this 
(Warren  Museum,  6529). 


Fig.  423. — Fracture  of 
shaft  of  femur  high  up  ; 
union  with  much  displace- 
ment (Warren  Museum, 
specimen  5993)- 


general  health,  the  operation  may  be  done  with  ever\'  prospect  of 
success. 

Supracondyloid  Fracture  of  the  Femur. — The  deformity-  is 
characteristic  and  fairly  typical  (see  Figs.  426,  427) ;  displacement 
of  both  fragments  backward  is  sometimes  seen  (see  Fig.  432). 
The  upper  end  of  the  lower  fragment  is  displaced  backward, 
chiefly  through  the  pull  upon  it  by  the  gastrocnemius  muscle. 

Treatment  of  this  fracture  in  the  straight  and  extended  position 
is  usually  unsatisfactory'.  It  is  necessars'  either  to  flex  the  leg  in 
order  to  relax  the  gastrocnemius  muscle  or  to  do  a  tenotomy  upon 


SUPRACONDYUUID  I'RACTURE 


301 


the  tendo  Achillis.  One  of  lliese  procedures  liaving  been  carried 
out,  the  thigh  and  leg  should  then  be  placed  upon  a  double  inclined 
plane  (see  Fig.  434).  Pressure  by  pads  may  be  exerted  upon  the 
upper  end  of  the  lower  fragment  in  order  to  lift  it  forward  into  ap- 
position with  the  upper  fragment.  Slight  traction,  if  possible, 
should  be  maintained  upon  the  lower  fragment.  Repeated  ex- 
aminations with  the  fluoroscope  will  indicate  when  reduction  is 
completed. 

The  After-treatment  and  Progress  of  Fracture  of  the  Thigh. 
— Inspection  of  the  fractured  limb  should  be  made  at  least  daily. 


Fig.  424. — Fractures  of  base  of  neck  and 
trochanters  of  femur.  View  from  behind 
and  inner  side  (Warren  Museum). 


Fig.  425. — Fracture  well  below  trochan- 
ters, with  a  split  running  upward  through 
great  trochanter.  Also  fracture  of  neck  of 
bone  with  displacement  of  head  up  and 
out.  Recent  case  (Warren  Museum,  speci- 
men 1074). 


Measurement  should  be  made  twice  a  week  during  the  first  few 
weeks,  the  internal  malleolus  being  reached  through  the  bandage. 
Parts  of  the  apparatus  may  need  changing,  and  straps  may  re- 
quire tightening  or  loosening.  The  heel  and  sacrum  will  require 
attention  because  of  the  constant  pressure  from  lying  in  one  posi- 
tion. 

Ordinarily,  there  will  be  little  or  no  pain  associated  with  the  re- 
pair of  the  fracture.  After  about  four  weeks  all  apparatus  should 
be  removed  and  the  limb  thoroughly  inspected,  to  detect,  if  possi- 
ble, any  uncorrected  deformity,  and  to  determine  whether  union  is 
yet  firm.     In  from  four  to  six  weeks  repair  in  a  healthy  child  or 


302 


FRACTURES    OF    THE    FEMUR 


voung  adult  should  have  advanced  to  the  stage  of  firm  union. 
The  apparatus  should  then  be  reapplied.  At  the  end  of  the  eighth 
week  all  apparatus  should  be  finally  removed.  The  thigh  should 
be  washed  and  thoroughly  oiled.  The  patient  should  be  permitted 
to  lie  in  any  position  in  bed  without  retentive  apparatus  for  one 
week.  After  the  splints  are  first  left  off  and  while  the  patient  is 
still  in  bed  daily  systematic  massage  to  the  whole  limb  should  be 
practised,  together  with  slight  passive  and  active  motion  at  the 
knee-joint.  The  patient  should  not  be  allowed  to  bear  weight  upon 
the  unprotected  thigh  until  after  the  ninth  week.  At  the  ninth 
week  he  should  be  allowed  up  and  about  with  crutches,  and  a  mod- 
erately high-soled  shoe  (two  inches)  should  be  worn  upon  the  foot 


Upper  fragment  of  femur. 


Lower  fragment  of  femur. 


Gastrocnemius  muscle. 


Patella. 


Tibia. 


Fibula. 


Fig.  426. — Action  of  gastrocnemius  muscle  pulling  distal  fragment  backward  and  downward. 


of  the  uninjured  thigh.  He  should  bear  no  weight  upon  the  in- 
jured leg.  The  seat  of  the  fracture  should  be  protected  by  coapta- 
tion splints  and  straps  and  a  light  spica  plaster-of-Paris  bandage 
from  the  toes  to  above  the  waist.  At  the  end  of  twelve  weeks  all 
support  may  be  discarded.  Of  course,  fractures  of  the  femur 
vary  considerably  in  the  time  the  patient  is  able  to  get  about,  but 
the  foregoing  routine  is  that  of  average  uncomplicated  cases. 

It  is  very  probable  that  massage  without  any  passive  motion,  as 
early  as  the  second  week,  to  the  region  of  the  knee  and  thigh,  will 
prevent  much  of  the  knee-joint  disability  and  muscular  atrophy 
that  so  often  hinder  convalescence  in  these  cases.  It  is  very  im- 
portant also,  in  order  to  gain  this  end,  to  see  that  the  extension  is 


THE  AMHlLAToRY  TREATMENT 


303 


mack'  rroin  around  and  aboxf  IIk'  condxU-s  of  the  femur  and  not,  as 
so  oflfu  ha])]K'ns,  from  llic  knee  joint  itself.  It  ought  to  be 
possible  to  avoid  all  knee-joint  stiffness  by  the  judicious  use  of 
massage  to  the  whole  limb  and  passive  motion  to  the  knee-joint. 
These  measures  in  many  cases  should  be  instituted  and  practised 
regularly  and  persistently  and  always  cautiously  from  the  second 
week  after  the  injury. 

The  ambulatory  trcaiiuoit  of  jraciiirc  of  the  thigh  by  means  of  the 
long  Tavlor  hip  traction  splint,  a  high  sole  upon  the  shoe  worn  on 
the  well  foot,  and  crutches,  is  of  ver\'  great  value,  especially  in 
children  and  young  adults.  The  hip-splint,  consisting  of  a  long 
outside  upright,  pelvic,  thigh,  and  calf  bands,  is  applied  with  two 


Shaft  of  femur. 


Condyles  and  lower  fra^ 
nient  of  femur. 


Tibia. 


Fig.  427. — Low  fracture  of  the  shaft  of  the  femur.  Displacement  of  the  lower  fragment 
backward  by  the  gastrocnemius  muscle,  and  of  the  upper  fragment  forward.  Overlapping 
of  fragments. 


perineal  straps  (see  Figs.  435,  436).  The  traction  is  made  through 
the  windlass  at  the  foot-piece  after  fastening  the  extension  strips 
to  it.  The  countertraction  is  made  by  the  two  perineal  straps. 
The  thigh  is  securely  held  by  coaptation  splints  and  a  bandage 
about  the  thigh  and  splint.  The  patient  goes  about  with  crutches 
and  a  high  sole  of  t\\o  inches  upon  the  shoe  worn  on  the  well  foot, 
bearing  a  little  weight  upon  the  foot  of  the  splint.  As  a  matter  of 
fact,  the  real  value  of  this  method  in  fracture  of  the  thigh  lies  in 
the  improvement  to  the  general  health  by  the  early  getting  into  the 
upright  position  and  out  of  bed.  This  application  of  the  ambula- 
tor}" method  certainly  is  of  great  comfort  to  the  patient.  That  it 
hastens  the  reparative  process  is  yet  to  be  fully  demonstrated.     If 


304 


FRACTURES    OR    THE    FEMUR 


the  Taylor  hip-splint  is  used,  it  should  be  applied  when  union  is 
found  to  be  firm.  After  wearing  the  splint  in  bed  for  a  few  days 
the  patient  may  get  up  and  be  about. 

The  Prognosis. — AVhat  shall  be  considered  a  satisfactory  result 
in  the  treatment  of  a  closed  fracture  of  the  shaft  of  the  femur? 
The  degree  of  restoration  of  function  can  not  be  determined  with 
accuracv  until  about  one  year  has  elapsed  after  treatment  is  sus- 
pended. The  following  six  requisites  for  a  satisfactory  result  fol- 
lowing fracture  of  the  femur  are  those  reported  by  a  committee 


Fig.  428.— Lateral  view.  Oblique  fracture  of  the  shaft  of  the  femur  low  down.  Little 
backward  displacement  of  lower  fragment.  Considerable  shortening  of  thigh  from  forward 
displacement  of  upper  fragment.     Man  aged  forty.     Recovery. 


from  the  American  Surgical  Association,  and    generally  accepted 
as  forming  a  good  working  basis. 

For  a  result  to  rank  as  a  good  one,  it  must  be  established  that 
firm  bony  union  exists ;  that  the  long  axis  of  the  lower  fragment  is 
either  directly  continuous  with  that  of  the  upper  fragment  or  is  on 
nearly  parallel  lines,  thus  preventing  angular  deformity ;  that  the 
anterior  surface  of  the  lower  fragment  maintains  nearly  its  normal 
relation  to  the  plane  of  the  upper  fragment,  thus  preventing  undue 
deviation  of  the  foot  from  its  normal  position ;  that  the  length  of 


PROGNOSIS 


305 


Uk-  limb  is  exacll\-  equal  to  its  fellow  or  that  the  amount  of  short- 
ening falls  within  the  limits  found  to  exist  in  ninety  per  cent,  of 
healthy  limbs — namely,  from  one-eighth  to  one  inch ;  that  lame- 
ness, if  present,  is  not  due  to  more  than  one  inch  of  shortening; 
that  the  conditions  attending  the  treatment  prevent  other  results 
than  those  obtained. 

Results  After  Fracture  of  the  Thigh. — The  prognosis  as  to  the 
usefulness  of  the  thigh  after  fracture  deduced  from  the  statistics 
available  is  of  little  value,  because  the  details  of  the  cases  are  not 


Fig.  429.— Same  as  figure  428.     Anteroposterior  view. 


presented  nor  is  any  discrimination  made  between  the  seats  of 
fracture  and  the  ages  of  the  patients.  Realizing  these  facts,  I  have 
ver\'  carefully  examined  and  classified  the  final  results  several 
years  after  treatment  had  ceased  in  thirty-five  cases  of  uncompli- 
cated fracture  of  the  shaft  of  the  femur  treated  at  the  Massachu- 
setts General  Hospital.  The  treatment  in  all  cases  was  practically 
the  same :  a  Buck's  extension  with  outside  T-splint,  or  a  long  De- 
sault  apparatus,  and,  toward  the  end  of  treatment,  a  plaster  spica 
of  the  thigh,  groin,  and  trunk,  with  crutches.  Even  though  this 
number  of  cases  is  relatively  small,  yet,  after  having  most  care- 
20 


3o6 


FRACTURES    OF    THE   FEMUR 


fully  analyzed  them,  it  seems  highly  probable  that  even  if  this 
number  should  be  increased,  the  ultimate  results  would  not  ma- 
terially differ.  These  thirty-five  cases  have  been  arranged  in 
three  groups,  according  to  age :  (a)  Those  of  childhood ;  (b)  those 


Sequestrum. 


Fig.  430. — Oblique  fracture  of  the  shaft 
just  above  the  knee,  with  splitting  apart  of 
the  two  condyles.  Extreme  displacement ; 
necrosis  of  tip  of  upper  fragment.  Patient 
a  man  of  thirty-seven  years,  lived  for  five 
months  (Warren  Museum,  specimen  iiiS). 


Fig.  431. 


-Same  as  figure  430,  view  from 
behind. 


Upper  fragment  of  femur 


Lower  fragment  of  femur.— 


Patella. - 


Fig.  432. — Transverse  fracture  of  the  femur  in  the  lower  third  with  backward  displacement 
of  both  fragments.     Lateral  view. 


of  adult  life;  and  (c)  those  of  old  age.  (a)  Fourteen  cases  oc- 
curred in  childhood,  the  ages  averaging  seven  and  a  half  years. 
Patients  were  heard  from  or  reported  for  examination  one  and  a 
half  to  seven  years  after  the  original  injury.  All  cases  were  treated 
by  bed  extension,  coaptation  splints,  and  the  plaster  spica  to  thigh 


PROGNOSIS 


307 


and  liip.  All  have  perfect  functional  results.  Four  cases  men- 
tion slight  pain  occasionally.  Three  of  these  four  cases  have  a  little 
stiffness  of  the  knee  upon  the  injured  side  one  and  a  half  years  after 
the  accident,  three  and  a  half,  and  three  years  respectively.  (6) 
Sixteen  cases  occi:rred  in  adults  whose  ages  ranged  from  eighteen 
to  forty -eight  years.  These  were  seen  or  reported  from  one  to  six 
years  after  the  original  injur}'.  Five  of  these  have  unqualifiedly 
perfect  results,  without  pain  or  stiffness.  The  remaining  eleven 
cases  have  limited  knee-joint  movements,  aching  in  the  thigh,  pain 


Upper  fragment. 


—  Lower  fragment. 


Fig.  433. — Same  as  figure  432.     Anteroposterior  view,  showing  lateral  displacement. 


Fig.  434. — Diagram  of  double  inclined  plane  for  fractures  near  the  lower  end  of  the 
femur.  Secures  good  position  through  relaxation  of  gastrocnemius  muscle  and  pads  beneath 
lower  fragment. 


after  exercising,  pain  in  wet  weather,  weakness  in  the  whole  leg, 
and  slight  lameness  in  walking,  (c)  Five  cases  occurred  during 
old  age.  The  patients  averaged  fifty-eight  years.  These  were 
seen  or  reported  from  two  to  six  3'ears  after  the  original  injury. 
None  has  functionally  perfect  results.  There  is  one  case  of  non- 
union of  the  thigh  with  shortening  of  the  limb.  Two  cases  must 
use  a  cane  in  walking.  The  knee  is  painful  and  motion  is  limited 
in  all  cases.  Swelling  of  the  leg  is  not  uncommon,  and  pain  in  wet 
weather  is  vers*  commonly  complained  of  by  these  old  people. 


3o8 


FRACTURES    OF    THE    FEMUR 


Considering  these  reported  cases  individually  and  grouped 
according  to  the  three  age  periods,  it  seems  reasonable  to  conclude 
that  they  form  a  basis  for  a  fairly  accurate  judgment  as  to  the 
probable  outcome  of  these  injuries  to  the  shaft  of  the  femur.  As 
the  age  increases  the  liability  to  impairment  of  the  function  of  the 
limb  increases.  This  liability  is  very  great  after  fifty  years  are 
passed. 


Fig-  435-— Fracture  of  the  thigh.  Con- 
valescent ambulatory  splint  without  trac- 
tion. 


Fig.  436. — Fracture  of  the  thigh.  Con- 
valescent ambulatory  splint  without  trac- 
tion. Coaptation  splints  may  be  applied  to 
the  thigh  and  held  by  straps  inclosing  the 
splint. 


It  is  not  very  uncommon,  even  in  closed  fractures  of  the  femur, 
to  find  gangrene  of  the  leg  developing  because  of  laceration  or  pres- 
sure upon  the  great  vessels  of  the  limb.  Early  amputation  of  the 
thigh  just  above  the  fracture  will  be  necessary  in  these  cases.  It 
should  be  done  early  in  order  to  save  life.  In  the  aged  the  shock 
of  the  accident  may  prove  fatal.     In  open  fractures  the  violence, 


TREATMENT   IN    CHILDHOOD 


309 


usually  direct,  has  bccMi  so  great  that  the  soft  parts  about  the  knee 
and  throughout  the  whole  thigh  have  been  greatly  torn  and  lacer- 
ated on  either  side  of  the  fractured  bone.  The  shock  in  these  cases 
is  severe.      Recovery  is  always  doubtful. 

Fracture  of  the  Thigh  in  Childhood. — This  is  usually  caused  by 
direct  violence.  The  fracture  is  often  incomplete.  The  symp- 
toms are  those  of  the  same  fracture  in  the  adult.     The  effusion 


r 

-y^ 

f ' 

1 

^ffiS 

iM    -^^ 

^^^HL  '**^T1 » 

--;?»  '' 

«ri 

^^^K        flH^ 

^3HH^^ 

F'ig.  437. — Fracture  of  the  left  thigh  at  the  middle.     Union  solid.     Convalescence  hastened 
by  use  of  hip  splint  with  fixation  of  thigh  by  coaptation  splints  and  straps. 


into  the  knee-joint  is  seen  perhaps  more  uniformlv  than  in  the 
adult.  This  effusion  disappears  from  the  child's  knee-joint  more 
quickly  than  from  the  adult  knee-joint. 

Treatment. — After  reducing  the  fracture, — making  the  incom- 
plete fracture  complete  if  perfect  reduction  can  not  be  accom- 
plished in  any  other  way, — the  problem  of  maintaining  the  reduc- 
tion arises. 


3IO 


FRACTURES    OF    THE    FEMUR 


=^ 


In  children  of  ten  years  and  older  it  is  possible  to  use  the  Buck's 
extension.  A  plaster-of- Paris  spica  splint  from  the  calf  of  the  leg 
to'the  axilla  is  also  a  possible  method  of  immobilization. 

In  children  under  ten  years  of  age  the  Cabot  posterior  wire 
frame  with  coaptation  splints  and  extension  is  the  very  best 
method  of  conveniently  and  efficiently  treating  a  fractured  thigh 
or  fractured  hip. 

The  Cabot  Posterior  Wire  Sphnt  (see  Fig.  438) :  The  splint  con- 
sists of  two  portions — a  body  part  and  a  leg  part.     The  patient 
lies  upon  the  body  part  with  the  thigh  and  leg  resting  upon  the 
leg  part,  as  upon  a  coaptation  sphnt.     Having 
A  D         a,  vise  and  simple  iron  wire  the  size  of  an  or- 

dinary lead-pencil,  this  splint  can  be  made  in 
a  few  moments ;  the  bending  of  the  wire  ac- 
cording to  the  diagram  and  fastening  the  free 
ends  by  a  strip  of  small-sized  wire  being  all  that 
are  required.  It  is  necessary  to  make  the  fol- 
lowing measurements  before  bending  the  wire 
to  the  general  shape  shown  in  the  diagram — 
namely,  D  E,  the  distance  from  the  axilla  to 
the  calf  of  the  leg ;  A  D,  the  width  of  the  trunk ; 
A  B,  from  the  axilla  to  a  point  midway  between 
the  crest  of  the  ilium  and  the  top  of  the  great 
trochanter;  F  E,  the  width  of  the  leg,  usualty 
from  two  to  two  and  a  half  inches.  A  D  and 
B  C  are  bent  to  the  curve  of  the  back.  B  C  is  so 
bent  that  it  jumps  over  the  sacrum  and  does  not 
touch  posteriorly  excepting  at  B  and  C.  The 
long  rods  are  so  bent  as  to  adapt  them  to  the  posterior  curves  of 
the  buttock,  thigh,  popliteal  space,  and  leg  (see  Fig.  439).  The 
sphnt  is  covered,  as  in  the  posterior  wire  splint  for  the  leg,  by 
layers  of  sheet  wadding  and  cotton  bandages.  A  swathe  is  at- 
tached to  the  two  sides  A  B  and  D  H  of  the  body  part  (see  Figs. 
438  and  440).  The  child  is  carefully  laid  upon  this  splint,  the 
body  swathes  adjusted,  the  extension  strips  applied,  traction  made 
by  weight  and  pulley  with  the  foot  of  the  bed  elevated,  coaptation 
sphnts  apphed  and  held  in  position  by  straps  that  include  the  pos- 
terior wire  sphnt.     If  it  is  necessary  to  move  the  child  for  the 


Fig.  438.  —  Cabot 
wire  splint  for  fracture 
of  the  hip  and  thigh. 


TREAT.MKNT    IX    CHILDHOOD  3 II 

making  of  the  bed,  for  the  use  of  the  bed-pan,  or  for  bathing,  the 
extension  may  be  unfastened  temporarily  without  any  injury  to 
the  fracture,  particularly  if  the  coaptation  splints  are  then  tem- 
porarily tightened  to  secure  a  firmer  hold  on  the  thigh.     The  child 


Fig.  439.— The  Cabot  wire  splint  ready  for  use.     Lateral  view,  showing  curves  of  splint  cor- 
responding to  small  of  back,  buttock,  and  knee. 


Fig.  440. — The  Cabot  wire  splint  ready  for  use.     Front  view,  showing  covering  of  Canton 
flannel  and  Canton-flannel  double  swathe  for  fixation  to  chest. 


should  be,  of  course,  clean  from  both  urine  and  feces,  and  the 
fracture  immobilized. 

After  four  weeks  of  bed-treatment  the  child  may  be  up,  with 
crutches  and  a  high  shoe  with  the  Cabot  splint  applied.     Shoulder- 


312 


FRACTURES    OF    THE    FEMUR 


straps  should  be  attached  to  the  sphnt  when  it  is  worn  in  the  erect 
position.  This  is  one  of  the  simplest,  cleanest,  and  most  efficient 
methods  of  treating  fracture  of  the  thigh  in  young  children.  The 
child  can  be  moved  with  freedom  and  without  pain.  A  light 
plaster-of- Paris  spica  bandage  may  be  used  in  convalescence  with 
crutches  and  a  high  shoe  on  the  uninjured  side. 


Fig.  441.— Bradford  bed-frame  for  fixation  of  trunk  in  fracture  of  the  thigh. 


Fig.  442.— Fracture  of  thigh  in  a  child.  Bradford  frame.  Vertical  suspension  of  leg  with 
weight  and  pulley.  Coaptation  splints  to  thigh  and  fixation  of  pelvis  by  towel  swathe  about 
frame. 


In  verv^  small  children  it  is  sometimes  wise  to  use  the  Bradford 
(see  Fig.  441)  frame  and  vertical  suspension  (see  Fig.  442)  of  one 
or  both  thighs.  This  is  an  efficient,  comfortable,  and  clean  method 
of  treatment.  The  Bradford  frame  is  an  iron,  frame-hke  stretcher, 
on  which  the  child  lies  and  to  which  the  shoulders  and  hips  are 
fastened  to  prevent  the  child's  moving  about.     Counterextension 


TRKATMUNT    IN    CHILDHOOD 


313 


is  then  secured  by  the  imniobihzation  (jf  the  pelvis  and  hip.  The 
extension  is  appUed  to  the  thigh  and  leg  as  usual.  The  limb  is 
flexed  on  the  body  to  a  right  angle,  coaptation  splints  being  ap- 
plied to  the  thigh.  After  the  novelty  of  the  position  passes  away, 
the  child  is  perfectly  contented.  As  soon  as  union  is  firm,  the 
permanent  plaster  spica  dressing  may  be  applied,  and  the  patient 
may  be  up  and  about  with  high  shoe  upon  the  well  foot  and  with 
crutches.     The  use  of  the  long  hip-splint  will  be  of  great  service 


Fig.  443. — Old  fracture  of  the  ihi,:;li  with  ^lelorniit\-.     Due  to  use  of  unprotected  thigh  before 
complete  consolidation  of  fracture  (Warren). 


in  these  cases  either  with  or  without  the  extension  foot-piece  (see 
Figs.  435,  436).  After  fracture  of  the  shaft  of  the  femur  in  chil- 
dren there  should  be  no  shortening  and  no  special  difficulty  in  con- 
valescence. It  is  wase  to  guard  the  thigh  a  sufficient  time  after 
union  is  firm  to  insure  absolute  solidity  and  freedom  from  bowing 
in  any  direction  (see  Fig.  443). 

The  Making  of  the  Bradford  Frame. — It  is  most  easily  made 
from  f-  to  ^-inch  gas  piping.     It  should  be  one  inch  wider  than 


314 


FRACTURES    OF    THE    FEMUR 


the  width  of  the  hips,  and  six  inches  longer  than  the  height  of 
the  child.     It  should  be  covered  with  canvas,  so  as  to  leave  a 

space  under  the  buttocks  for  the  use  of 

the  bed-pan. 


SEPARATION  OF  THE  LOWER  EPIPH- 
YSIS OF  THE  FEMUR 

Anatomy. — The  lower  epiphysis  of  the 
femur  is  the  largest  of  the  epiphyses.  It 
unites  with  the  shaft  of  the  bone  at  or 
about  the  twenty-first  year.  The  epiph- 
ysis includes  the  whole  of  the  articular 
surface  of  the  lower  end  of  the  femur.  The 
points  of  origin  of  the  gastrocnemii  mus- 
cles are  situated  upon  the  epiphysis;  a 
few  fibers  only  arise  from  the  diaphysis. 
The  inner  condylar  line  of  the  femur  is 
continuous  with  the  inner  lip  of  the  linea 
aspera,  and  terminates  at  the  adductor 
tubercle,  which  can  be  palpated  upon  the 
inner  side  of  the  thigh  near  the  knee- 
joint.  The  upper  and  outer  angle  of  the 
trochlear  surface  of  the  femur  can  be  pal- 
pated best  with  the  knee  flexed.  A  line 
drawn  from  this  angle  of  the  trochlear  to 
the  adductor  tubercle  marks  the  level  of 
the  lower  epiphysis  of  the  femur  (see  Fig. 
444).  In  no  position  of  the  knee-joint  are 
the  bones  in  more  than  partial  contact. 
This  is  one  of  the  superficial  joints  of  the 
body.  The  strength  of  the  joint  lies  in 
the  ligaments  and  fasciae  about  it.  Un- 
like the  elbow-  and  hip-joints,  it  does  not 
depend  upon  the  contour  of  the  bones  for 
strength.  An  attempt  to  overextend  and  to  bend  the  knee 
laterally  brings  very  great  strain  to  bear  upon  the  ligaments  that 
are  attached  to  the   lower  femoral  epiphysis.     If  this  strain  is 


Fig.  444. — Femoral  epiph- 
yses at  fifteen  years.  Note  re- 
lations of  lower  epiphyseal  line 
to  inferior  articular  surface. 


SEPAKATIUN    UF    THE    LOWER    EPIPHYSIS 


3^5 


of  sufficient  force,  the  epiphyseal  cartilage  gives  way,  and  the 
epiphysis  separates  from  the  shaft  of  the  femur.  The  common 
cause  of  the  accident  is  the  catching  of  the  leg  or  thigh  in  the  spokes 
of  a  revolving  wheel.  The  accident  most  often  occurs  to  boys 
about  ten  years  old  (see  Figs.  445,  446). 

The  epiphysis  usually  separates  without  splintering  the  diaph- 
ysis.     The   periosteum   is   stripped   for  a   considerable   distance. 


Fig.  445. — Case  :  Boy,  eleven  years  of  age.  Separation  of  the  lower  femoral  epiphysis. 
Photograph  taken  four  hours  after  the  injury.  Note  inversion  of  the  limb  ;  fullness  of  lower 
third  of  thigh  posteriorly  ;  fullness  over  head  of  tibia  ;  fullness  in  popliteal  space  (X-ray 
tracing.  Fig.  447,  explains  the  evident  deformity). 


Fig.  446. — Case  same  as  figure  ^4.5.     ^epilation  of  the  lower  femoral  epiphysis  of  the  left  le 
Contrast  two  knees  (see  X-ray  tracing,  Fig.  447). 


About  half  the  cases  are  open,  the  end  of  the  diaphysis  projecting 
through  the  skin  of  the  popliteal  space.  The  knee-joint  is  usually 
unopened.  There  may  be  almost  no  displacement  of  the  frag- 
ments. A  lateral  sliding  of  the  epiphysis  has  often  been  observed. 
One  condyle  has  been  found  in  the  popliteal  space,  but  commonly 
the  epiphysis  lies  in  front  of  the  shaft  of  the  femur  with  its  sepa- 
rated surface  in  contact  with  the  shaft  (see  Figs.  447,  448,  449). 
The  diaphysis  is  displaced  backward  and  downward  into  the  popli- 


3i6 


FRACTURES    OF    THE    FEMUR 


teal  space,  because  of  the  possible  high  attachment  of  the  gastroc- 
nemii  and  the  fracturing  force.  The  nerves  of  this  region  may  be 
pressed  upon  or  lacerated,  and  this  may  be  the  cause  of  great  pain 
attending  the  accident.  The  popliteal  vessels  may  be  compressed, 
stretched,  or  even  ruptured.  Consequently,  interference  with 
the  circulation  may  result.  This  may  be  moderate  and  tempor- 
ary, or  extreme  and  result  in  gangrene  of  the  leg.  The  shock 
attending  this  accident  is  often  great.  Suppuration  may  appear 
in  closed  separations,  although  it  is  infrequent ;  it  is  much  more 


Diaphjsis  of  femur. \ 


Lower  femoral 

epiphysis. 


--Condyle  of  femur. 

..  .Upper  epiphysis 
of  tibia. 


,Diaphysis  of  tibia. 
.Fibula. 


Fig.  447. — Lateral  view.  Case  of  iigure  445.  Boy,  aged  eleven  years.  Separation  of  the 
lower  femoral  epiphysis.  Displacement  forward  of  epiphysis  and  backward  of  lower  end  of 
shaft  (see  Figs.  445,  446.    X-ray  tracing). 


likely  to  appear  in  open  lesions.  Sloughing  of  the  skin  is  not  un- 
usual from  the  bony  pressure.  Gangrene  of  the  leg  sometimes 
occurs.  Necrosis  of  bone  is  not  unlikely  to  result,  particularly  if 
the  separation  of  the  periosteum  is  great  (see  Fig.  450). 

Diagnosis. — After  severe  trauma  to  the  region  of  the  knee 
there  are  three  injuries  that  should  be  considered  possible :  a  dis- 
location of  the  knee-joint,  a  supracondyloid  fracture  of  the  femur, 
or  a  separation  of  the  lower  epiphysis  of  the  femur. 

There  may  be  so  much  swelling  that  a  satisfactory  examination 
is  impossible.     Ordinarily,  careful  palpation  will  detect  the  bony 


SEPARATION    OF    THH    LoWKK    HPIPHYSIS 


317 


outlines  of  a  dislocation.  This  is  txtrcnicly  raix-  in  children.  The 
crepitus  of  a  supracondyloid  fracture  is  bony  and  hard,  and  the 
displacement  of  the  distal  fragment  into  the  popliteal  space  evi- 


Epiphyseal  line. 

Lower  femoral  epiphysis. 


Epiphyseal  line  of  tibia.-  — 
Epiphyseal  line  of  fibula. 


Fig.  448.— Same  case  as  figure  447.     Anteroposterior  view  of  uninjured  knee  in  a  child  eleven 
vears  of  age,  showing  epiphysis  in  position  (X-ray  tracing). 


7 Lower  femoral  epiphysis. 


Epiphyseal  line  of  tibia. 
Epiphyseal  line  of  fibula. 


Fig.  449. — Same  case  as  figure  447.   Anteroposterior  view  of  displaced  lower  femoral  epiphysis 
in  a  boy  eleven  years  old. 


dent.  All  fractures  at  the  knee  are  not  necessarily  supracondy- 
loid. Several  cases  of  fracture  of  one  condyle  of  the  femur  into 
the  joint  are  reported.     The  separated  epiphysis  itself  may  be  split 


3i8 


FRACTURES    OF    THE    FEMUR 


through  into  the  joint.  A  severe  trauma  to  the  knee,  a  cart-wheel 
accident  to  a  young  boy,  attended  by  considerable  shock,  followed 
by  great  swelling  of  the  knee,  a  fullness  in  the  popliteal  space, 
feeble  or  absent  pulsation  in  the  dorsalis  pedis  and  posterior  tibial 
arteries,  increased  lateral  and  anteroposterior  mobility  at  the  knee, 
and  soft  crepitus  form  the  picture  characteristic  of  a  separation  of 
the  lower  femoral  epiphysis. 

Prognosis. — It  is  impossible  to  state  positively  that  in  any  given 
case  there  will  or  will  not  be  shortening  of  the  leg  upon  the  injured 

Lower  femoral  epiphysis. 
/' 


Patella. 


Diaphysis  of  femur.— — 


•  —Upper  epiphysis  of 
tibia. 


—  —  Diaphysis  of  tibia. 


Fig.  450. — Separation  of  lower  epiphysis  of  the  femur  with  displacement  forward  and  upward 
between  femoral  diaphysis  and  patella  (Warren  Museum,  8116-1). 


side  because  of  a  cessation  of  growth  in  the  femoral  epiphysis.  If 
the  epiphysis  is  separated  without  great  laceration  and  periosteal 
denudation  and  is  replaced  soon  after  the  injury,  the  chances  are 
that  there  will  be  a  minimum  amount  of  shortening  of  the  affected 
leg.  After  open  incision  and  replacing  of  the  epiphysis  in  closed 
fractures  good  results  are  to  be  expected  as  far  as  the  usefulness  of 
the  joint  is  concerned.  Slight  necrosis  of  bone  may  attend  con- 
valescence. If  the  separation  is  closed  and  reduction  is  impossible 
by  manipulation  alone,  open  incision  should  be  made. 

Treatment. — If  the  vessels  are  torn;  if  there  is  great  laceration 


SEPARATION   OF   THE   LOWER    EPIPHYSIS 


319 


of  the  soft  ])arts,  ainpulalion  should  be  performed.  If  the  sepa- 
ration is  open  and  the  shaft  of  the  femur  protrudes  through  the 
wound,  and  much  of  the  diaphysis  is  seen  to  be  denuded  of  perios- 
teum, the  diaphysis  should  be  resected  to  the  limit  of  periosteal 
separation,  and  then  the  bone  reduced.  It  may  be  necessary  to 
enlarge  the  opening  in  the  soft  parts  before  it  is  possible  to  reduce 
the  bone.  If  the  separation  is  closed,  reduction  by  manipulation 
should  be  attempted;  if  successful,  the  leg  should  be  flexed  to  a 


Fig.  451. — Method  of  grasping  knee  to  reduce  a  displaced  femoral  epiphysis.     Note  thumbs 
at  anterior  border  of  epiphysis  and  fingers  upon  the  lower  end  of  the  femoral  diaphysis. 


right  angle  or  an  acute  angle  and  immobilized  in  a  plaster-of-Paris 
splint. 

Reduction  by  Manipulation  When  the  Fragment  is  Displaced 
Forward. — While  an  assistant  makes  traction  upon  the  leg,  the 
surgeon,  grasping  the  thigh  above  the  condyles  with  the  fingers  in 
the  popliteal  space,  making  pressure  on  the  upper  fragment,  pushes 
with  his  two  thumbs  upon  the  upper  border  of  the  displaced  epiph- 
ysis (see  Fig.  451 ).  The  leg  is  gradually  flexed.  If  the  reduction 
is  achieved,  a  soft  grating  sensation  will  have  been  felt,  and  the 
shortening  of  the  leg  that  existed  previous  to  reduction  will  disap- 


320 


FRACTURES    OF    THE    FEMUR 


pear.     The  contour  of  the  knee  will  assume  a  somewhat  normal 
appearance. 

The  Operative  Method  of  Reduction. — The  obstacle  to  reduction 
is  no  single  band  or  obstruction,  it  is  the  retraction  and  tension 
maintained  by  the  fasciae,  ligaments,  and  muscles  of  the  thigh 
upon  the  tibia.  This  retraction  is  so  great  that  the  tibia  is  held 
crowded  against  the  lower  end  of  the  upper  fragment,  and  prevents 
the  replacing  of  the  epiphysis.     An  incision  is  best  made  over  the 


Fig.  452. — Diagram  to  show  method  of  reduction  of  separated  femoral  epiphysis  by  incision. 
Retractors  are  upon  diaphysis  and  epiphysis,  and  lines  of  traction  are  shown  by  arrows. 


Fig.  453. — Cabot  splint  arranged  as  double  inclined  plane  for  epiphyseal  separation  at  the 
lower  end  of  femur.  B,  The  part  behind  the  knee-joint,  may  be  bent  to  a  more  acute  angle  ; 
C,  the  body  portion,  is  to  be  molded  to  the  trunk  ;  A,  the  foot-piece.  With  the  angle  at  B 
obliterated,  the  splint  may  be  used  for  fracture  of  the  leg  in  childhood. 


denuded  shaft  of  the  femur  on  the  outer  side  of  the  leg.  The  shaft 
and  the  epiphysis  are  exposed  in  the  wound.  Traction  should  be 
made  by  means  of  periosteal  retractors  upon  the  epiphysis,  and 
countertraction  upon  the  diaphysis  while  the  leg  is  slow^ly  flexed 
from  the  completely  extended  position,  as  indicated  in  the  figure 
(see  Fig.  450).  This  w411  result  in  the  reduction  of  the  displace- 
ment. Suture  of  the  bones  may  be  needed  to  retain  the  replaced 
epiphysis  in  position.     The  flexed  position  of  the  leg  wall  assist 


SEPARATION    OF    THE    LOWER    EPIPHYSIS 


321 


materially  in  retaining  the  fragment  in  position.  The  application 
of  a  light-weight  plaster-of- Paris  circular  bandage  from  the  toes 
to  the  groin,  with  the  leg  Hexed  to  a  right  angle,  will  immobilize 
the  parts. 

After-union  is  firm  between  the  epiphysis  and  shaft.  After 
three  or  four  weeks  the  leg  may  be  gradually  extended.  The  foot 
of  the  injured  leg  may  be  touched  to  the  floor  while  the  plaster 
splint  is  in  place  about  five  weeks  after  the  injury.  Slight  weight 
may  be  borne  upon  it.  The  plaster  should  be  removed  after  about 
six  weeks,  and  gentle  active  and  passive  motion  made  at  the  knee- 


Fig.  454. — Case  :  Boy,  aged  eleven  years.  Separation  of  left  lower  femoral  epiphysis  ;  in- 
cision, reduction.  Recovery.  After  six  months,  useful  leg.  Knee  motion  in  flexion  beyond 
a  right  angle  as  shown  (see  frontispiece  and  Figs.  445-4.50  inclusive). 


joint.  Massage  to  the  calf  of  the  leg  and  the  thigh  should  be  given 
daily.  A  flannel  bandage  applied  to  the  foot,  ankle,  leg,  and  thigh 
will  be  all  the  support  that  is  needed.  After  about  ten  weeks  the 
boy  should  be  allowed  to  step  on  the  foot  all  he  chooses.  At  first 
he  will  do  this  with  fear,  but  soon  with  confidence.  There  will 
usually  be  a  little  limitation  of  motion  in  the  knee-joint  (see  Figs. 

454,  455)- 

Traumatic  Gangrene,  Septicemia,  Malignant  Edema. — Fractures 
complicated  with  laceration  of  the  large  vessels  are  a  frequent 
cause  of  gangrene.  If  an  acute  infectious  process  starts  in  a  limb 
with  traumatic  gangrene,   the  gangrene  spreads  with    frightful 


322 


FRACTURES    OF    THE    FEMUR 


rapidity.  The  general  disturbance  is  very  great.  A  septicemia 
of  grave  type  results.  To  such  cases  in  which  there  is  much  gas 
formation,  associated  with  edema,  and  which  results  in  rapid  de- 
struction of  tissue,  the  name  malignant  edema  is  given.  The 
specific  bacillus  of  malignant  edema  will  be  discovered  in  the  blood 
and  tissues  far  above  the  wound  of  the  soft  parts. 


Fig.  455. — Case  same  as  that  in  figure  454.  Separation  of  lower  femoral  epiphysis.  Note 
degree  of  extension  possible  and  cicatrix  of  incision  six  months  after  operation.  Note  also 
absence  of  deformity. 


The  proper  treatment  is  early  high  amputation  with  stimulation 
of  the  heart  by  strychnin  and  alcohol. 

Fat  Eynholism. — Fat  embolism,  to  a  greater  or  less  degree,  ex- 
ists in  every  case  of  fracture.  It  is  most  evidently  present  in  those 
cases  associated  with  great  laceration  of  tissue  and  in  open  frac- 


SEPARATION    OK    THE    LOWER    EPIPHYSIS  323 

tures.  The  soft  fat  of  the  medullary  tissue  is  the  source  of  the  fat- 
drops  that,  getting  into  the  venous  circulation,  are  carried  directly 
to  the  pulmonary  capillaries,  where  they  lodge  unless  the  blood 
pressure  is  sufficient  to  force  them  out  of  the  lung  capillaries  on 
into  the  systemic  circulation.  They  then  lodge  in  the  brain,  kid- 
neys, or  other  organs.  The  danger  in  fat  embolism  is  that  the 
patient  may  die  from  asphyxiation,  due  to  the  imperfect  oxy- 
genation of  the  blood  because  of  the  rapid  occlusion  of  the  pul- 
monary' capillaries  with  fat  globules. 

Symptoms. — Symptoms  develop  within  twenty -four  to  seventy- 
two  hours  after  the  accident.  In  fatal  cases  facial  pallor  and  dis- 
tress are  followed  by  cyanosis.  The  patient  is  first  excitable,  rest- 
less, then  somnolent  and  comatose.  Death  occurs  from  asphyxia. 
The  temperature  is  usually  not  elevated.  Respiration  is  rapid. 
Hemoptysis  may  exist,  associated  with  pulmonar\'  edema.  Fat 
globules  will  be  found  in  the  urine  usually  upon  the  second  and 
fourth  days  after  the  accident,  for  they  are  eliminated  by  the 
kidney. 

A  difficulty  in  breathing,  cyanosis,  and  fat  found  in  the  urine 
may  be  the  only  evidences  of  a  fat  embolism.  The  prognosis  is, 
of  course,  dependent  upon  the  extent  of  the  embolism  and  the 
strength  of  the  heart.  The  occurrence  of  fat  embolism  is  not  un- 
common.    Death  from  fat  embolism  is  rare. 

Treatment. — Stimulation  of  the  heart  for  its  extra  work  is 
indicated.  Immobilization  of  the  fractured  part  to  prevent  more 
fat  from  getting  into  the  circulation  and  the  administration  of 
ox}-gen  to  relieve  asphyxia  are  important  in  the  treatment. 


CHAPTER  XIII 

FRACTURES  OF  THE  PATELLA 

Anatomy. — A  knowledge  of  the  anatomical  relations  of  the 
patella  is  necessary  to  a  perfect  understanding  of  the  fractures  to 
which  it  is  liable  (see  Fig.  456).     Attached  to  the  patella  upon  its 


Fig.  456.— Normal  patella:    i,  From  in  front;   2,  from  behind;   3,  from  inner  side;    4,  from 
outer  side  ;  5,  anteroposterior  section  ;  a,  b,  usual  seat  of  fracture. 


Patella. 


Synovial  membrane, 
cavity  of  joint. 


Fig.  457.— Horizontal  frozen  section  of  the  knee-joint,  shovi'ing   lateral   extent  of  synovial 
membrane  (Professor  Dwight's  specimen). 


upper  border  is  the  tendon  of  the  quadriceps  extensor  muscle. 
Upon  each  side  of  the  bone  are  attached  the  vastus  internus  and 
vastus  externus  respectively.  Below  the  insertions  of  the  vasti 
is  a  portion  of  the  low  attachment  of  the  fascia  lata  of  the  thigh. 

324 


ANATOMY 


325 


At  the  lower  border  of  the  patella  is  the  patellar  tendon.     This 
tendon  is  inserted  into  the  tubercle  of  the  tibia,  and  it  is  separated 


Fig.  45S. — Anteroposterior  frozen  section  of  the  knee-joint,  showing  extent  of  synovial  mem- 
brane superiorly  and  inferiorly  (Professor  Dwight's  specimen). 


Fig.  459. — Ligamentous  preparation  of  the  knee,  the  patellar  tendon  cut  just  below  the 
patella,  dissected  out,  and  reflected  downward.  Shows  the  lateral  expansions  of  the  quadri- 
ceps tendon  extending  to  the  tibia  (from  dissection  by  Professor  Dwight). 


from  the  head  of  the  tibia  by  a  bursa  and  a  pad  of  fat  tissue.     The 
tendon  of  the  quadriceps,  the  insertions  of  the  vasti  muscles,  and 


Fig.  460.— Skiagraph  of  normal  right  knee-joint  in  an  adult. 


326 


ANATOMY 


327 


the  paU-llar  U'lidon  aiv  all  rdUliniK  ms  with  ihc  slroiiK  fascia  lata 
surrounding  the  thigh.  Tht-  fascia  lata  is  attached  below  to  the 
condyles  of  the  femur,  the  sides  of  the  patella,  the  tubenjsities  of 
the  tibia,  the  head  of  the  fibula,  and  to  the  deep  fascia  of  the  leg  in 
the  popliteal  space.  The  patella  is  seen,  therefore,  to  lie  in  a 
strong  fibrous  sheath  that  encircles  the  knee  and  is  attached  to 


Fig.  4.61.— A,  Nearly  median  section  of  the  knee-joint,  the  convex  surfaces  of  the  femur 
and  of  the  patella  in  contact.  B,  Diagrammatic  view,  showing  position  in  which  the  patella 
is  subjected  to  a  strain  on  contraction  of  the  quadriceps,  the  probable  mechanism  of  many 
patellar  fractures. 

various  bony  prominences  (see  Figs.  457,  45S,  459).  The  synovial 
membrane  of  the  knee-joint  lies  directly  beneath  and  attached  to 
the  posterior  surface  of  the  patella.  Laterally  and  posteriorly  the 
synovial  membrane  lies  next  to  the  encircling  fascia  of  the  joint. 
The  deep  bursa  of  the  femur  lies  in  front  of  the  lower  end  of  the 
femur  beneath  the  quadriceps  muscles,  and  often  communicates 
with  the  knee-joint.     The  tubercle  of  the  tibia  is  on  a  level  with 


32  8  FRACTURES  OF  THE  PATELLA 

the  head  of  the  fibula.  The  outHne  and  anterior  surface  of  the  pa- 
tella can  be  palpated  throughout.  When  the  leg  is  completely  ex- 
tended and  is  at  rest,  the  patella  can  be  removed  from  side  to  side. 
The  numerous  longitudinal  striae  on  the  anterior  surface  of  the 
patella  can  be  detected.  In  these  the  tendinous  bundles  of  inser- 
tion of  the  rectus  are  embedded.  It  is  these  fibers  that  fold  in 
over  the  broken  patella  and  prevent  the  approximation  of  the  frag- 
ments.    The  ligament  of  the  patella  is  parallel  with  the  axis  of  the 

leg- 
Fracture  of  the  patella  occurs  through  either  muscular  contrac- 
tion (see  Fig.  461)  and  strain  or  through  direct  \dolence.    The  form 
of  the  fracture  is  not  altogether  dependent  upon  the  causative 


Skin. 
Quadriceps  fascia. 


Synovial  membrane  with  under- 
lying fat  tissue. 


Skin.  ri^ '  Joint  surface  of  patella. 


—  Point  of  reflexion  of  synovial 
Ligamentum  patellse.  .^_J^f^'-'^|  membrane. 

Skin. 

Fig.  462.— Diagram  of  anteroposterior  section  of  patella  and  tendons,  showing  the  small 
extrasynovial  portion  of  posterior  surface  of  the  bone. 

force.  The  fracture  wih  be  either  transverse  and  clean  cut  or 
comminuted  and  irregular.  The  knee-joint  is  generally  opened: 
i.  e.,  the  svnovial  membrane  is  generally  torn.  The  synovial  mem- 
brane is  reflected  from  the  posterior  surface  of  the  patella  some 
distance  from  the  most  inferior  tip  of  the  bone.  It  is  possible, 
therefore,  for  a  fracture  to  occur  at  the  lower  portion  of  the  bone 
for  some  considerable  distance  from  the  lower  edge  without  open- 
ing the  knee-joint  (see  Fig.  462 ). 

Symptoms.— There  are  pain  in  the  knee  and  immediate  dis- 
abihty,  var\4ng  from  partial  to  complete  loss  of  power  in  extension 
and  in  flexion.  The  patient  may  be  unable  to  rise  or,  if  he  can 
stand,  he  can  not  move  except  backward,  and  then  only  by  drag- 


EXPECTANT   TREATMENT  329 

ging  the  foot  of  the  injured  liiiil)  upon  the  ground.  The  patient 
is  often  unable  to  raise  the  heel  from  the  bed  when  lying  upon  the 
back.  Swelling  of  the  knee,  which  at  first  is  slight,  after  three  or 
four  hours  may  become  very  great  (see  Fig.  463).  The  swelling  is 
due  to  the  accumulation  of  blood  and  synovial  fluid  in  the  knee- 
joint.  A  traumatic  synovitis  exists.  The  immediate  swelling  of 
the  knee  may  become  great  enough  to  demand  an  incision  to  re- 
lieve the  tension  upon  the  skin,  to  prevent  sloughing  of  the  skin 
above  the  broken  patella.  Immediately  after  the  accident  crepitus 
mav  be  elicited  by  pressing  the  two  fragments  together.  When 
the  knee-joint  is  distended  by  fluid,  it  is  often  impossible  even  to 
detect  the  fragments  of  the  patella,  but  as  the  fluid  subsides  and 


463.— Case:  Right  knee  normal;  left  knee,  fracture  of  patella.     Two  days  after  accident. 
Observe  swelling  of  whole  knee.    Joint  filled  with  fluid. 


the  sulcus  between  the  bones  is  felt,  crepitus  can  again  be  detected. 
The  degree  of  the  separation  of  the  fragments  is  dependent  upon 
the  amount  of  distention  of  the  joint  and  upon  the  extent  of  the 
tearing  of  the  lateral  aponeurosis  (fascia  lata)  of  the  knee,  per- 
mitting muscular  contraction  and  retraction.  If  the  causative 
violence  is  associated  with  a  wound  of  the  soft  parts,  there  will  be 
evident  a  contusion  or  an  abrasion  of  the  skin  or  a  lacerated  wound 
opening  the  knee-joint,  making  the  fracture  an  open  one. 

Treatment. — The  indications  to  be  met  are  the  limitation  and 
removal  of  the  eftusion,  the  reduction  of  the  fragments,  the  main- 
tenance of  the  reduction  until  union  is  satisfactor\-,  and  the  res- 
toration of  the  functions  of  the  joint  to  its  normal  condition. 

The  Limitation  and  Removal  of  the  Effusion. — If  the  fracture  is 


330 


FRACTURES    OF    THE    PATELLA 


seen  before  there  is  great  swelling,  limitation  of  the  swelling  may 
be  effected  by  immobilization  of  the  knee  and  the  accurate  appli- 


Fig.  464. — Fracture  of  patella  ;  fibrous 
union.  Broadening  of  lower  fragment 
(Warren  Museum,  specimen  3652). 


Fig.  465. — Fracture  of  patella.  Fi- 
brous union  with  moderate  separation ; 
marked  tilting  forward  of  fragments  :  no 
enlargement  of  fragments.  View  from 
side,  a,  Fibrous  union;  b.  extent  of  ar- 
ticular surface  which  is  now  concave  (War- 
ren Museum,  specimen  1129). 


Fig.  466.— Fracture  of  patella  ;  union  with  long  fibrous  band  ;  separation  of  fragments  3K 
inches  (Warren  Museum,  specimen  5253). 


cation  of  an  elastic  rubber  bandage.     If  the  bandage  is  not  at 
hand,  sponge  compresses  may  be  used— viz.,  two  slightly  moist- 


EXPIvCTANT    TRKATMKNT 


331 


ened  bath  or  carriage  sponges  are  allowed  to  dry  under  pressure 
sufficient  to  llatten  them.  These  are  placed  upon  each  side  of  the 
knee  and  over  it,  and  are  held  by  a  few  turns  of  a  roller  bandage. 
Cool  water  is  the  poured  over  the  whole.  As  the  sponges  absorb 
the  water  they  enlarge,  causing  equable  and  firm  pressure  on  the 
knee,  thus  verv   materially   hindering  the  accumulation  of   fluid 


Fig.  467. — Fracture  of  patella ;  bony 
union ;  some  elongation  of  bone  as  a 
whole.  View  from  side  (Warren  Museum, 
specimen  6707). 


Fig.  46S.— Recent  fracture  of  patella 
with  comminution.  Probably  from  direct 
violence  (Warren  Museum,  specimen  1130;. 


Fig.  469. — Ham-splint  without  strap, 
showing  proper  length  and  relation  to 
thigh  and  leg  posteriorly. 


and  favoring  its  absorption.  These  wet  sponge  compresses  should 
be  left  in  position  for  from  twelve  to  twenty-four  hours,  and  then  a 
fresh  set  used. 

^Massage  skilfully  applied  to  the  whole  limb,  irrespective  of  the 
method  of  treatment  eventually  instituted,  will  not  only  assist  in 
the  absorption  of  the  fluid,  but  will  preser\-e  intact  the  muscles  of 
the  limb.     Massage  to  be  effective  should  be  applied  at  least  twice 


332 


Fractures  of  the  patella 


daily,  and  from  fifteen  minutes  to  half  an  hour  at  a  time.  Slight 
pain  will  be  felt,  but  after  a  time  massage  will  be  painless  and  give 
great  comfort. 

The  Reduction  of  the  Fragments. — No  attempt  should  be  made 
to  reduce  the  fragments  until  nearly  all  the  fluid  is  removed  from 
the  knee-joint.  Reduction  is  accomplished  by  immobilization 
of  the  knee-joint,  by  fixation  of  the  lower  fragment,  and  by  trac- 


Fig.  470. — Improper  method  of  applying  a  ham-splint.     The  knee-joint  is  not  immobilized. 
Flexion  is  possible.     Straps  i  and  2  are  insufficient. 


^1( 

j^BHI 

J^ 

^^^^j 

HI 

^^^^^^H 

1^^ 

Fig.  471. — Proper  method  of  applying  a  ham-splint.     The   third  adhesive-plaster   strap  (3) 
prevents  flexion  of  the  knee. 


tion  upon  and  fixation  of  the  upper  fragment.  The  leg  should  be 
extended  completely  and  the  knee  immobilized  either  upon  ham- 
splint  (see  Figs.  469,  470,  471)  or  upon  a  Cabot  posterior  wire 
splint.  The  ham-splint  is  preferably  made  from  a  plaster-of- Paris 
bandage.  The  lower  fragment  is  held  fixed  by  a  strap,  preferably 
of  adhesive  plaster,  placed  obliquely  about  the  leg  and  splint,  and 
fastened  to  the  splint  above  the  fragment  (see  Figs.  472,  473,  474, 


EXPECTANT    TREATMENT 


333 


475).  The  upper  fragment  is  drawn  down  first  by  elevation  of  the 
leg  upon  an  inclined  plane,  which  relaxes  the  quadriceps  extensor 
muscle,  then  by  traction  obtained  by  a  strap  passed  obliquely 
above  the  upper  fragment  and  fastened  to  the  splint  below^  the 


Fig.  472.— Expectant  method  of  treating  fracture  of  the  patella.  Leg  extended  on  pos- 
terior wire  splint.  Fragments  held  by  two  straps.  Fluid  has  left  the  joint.  ^,  Side  splints; 
B,  coaptation  splints  reflected. 


Fig.  473.-Expectant  method  of  treating  fracture  of  the  patella.     Same  as  figure  472,  with  the 
addition  of  coaptation  splints  to  the  thigh,  padding,  and  straps. 


fragment.  The  upper  strap  will  need  repeated  adjustment  as  the 
plaster  sHps  and  as  the  fluid  disappears  from  the  joint.  To  facili- 
tate traction  by  this  upper  strap,  the  quadriceps  muscle  should  be 
held  firmly  by  coaptation  splints  and  straps  encircHng  the  poste- 


334  FRACTURES  OF  THE  PATELLA 

rior  splint.  The  quadriceps  can  not  then  actively  pull  upon  the 
upper  fragment.  The  tendency  of  these  two  straps  thus  applied 
will  be  to  tilt  the  broken  surfaces  of  the  two  fragments  upward  and 
apart,  particularly  if  there  is  fluid  in  the  joint.  It  is  important, 
therefore,  to  place  a  third  strap  over  the  two  broken  edges  of  the 
fragments,  in  order  to  hold  them  down  to  their  proper  level  and  to 
assist  in  bringing  them  into  apposition.  The  coaptation  splints 
should  be  removed  at  every  massage  treatment,  the  upper  frag- 
ment being  steadied  by  an  assistant.  The  straps  about  the  patella 
need  not  be  removed  during  the  massage.     They  will  be  of  no  in- 


Fig.  474. — Expectant  method  of  treating  fracture  of  the  patella.  Same  as  figure  473,  with 
the  addition  of  two  lateral  splints,  padding,  and  straps.  A  posterior  wooden  splint,  seen 
better  in  figure  473,  and  elevation  of  the  limb. 

convenience.  As  soon  as  the  effusion  has  left  the  joint,  all  will 
have  been  gained  in  the  reduction  of  the  fracture  that  can  be 
gained  by  this  method. 

Aspiration  of  the  knee-joint  by  means  of  a  narrow  knife  incision 
or  by  means  of  a  large-sized  trocar  is,  if  done  under  strictly  anti- 
septic precautions,  and  forty -eight  hours  after  the  fracture,  often 
satisfactory  in  immediately  removing  the  bulk  of  the  effusion;  if 
firm  compression  is  then  made,  it  effectually  prevents  the  reac- 
cumulation  of  fluid. 

Maintenance  of  Reduction  until  Union  is  Satisfactory. — At  the 
end  of  about  four  or  six  weeks  from  the  injury  union  will  be  found. 


EXPECTANT   TREATMENT 


335 


All  lluid  will  have  left  Uic  joint.  The  releiitive  straps  and  coapta- 
tion splints  may  now  he  removed.  The  leg  should  be  immobilized 
by  means  of  a  plaster-of- Paris  splint  extending  from  just  below  the 
swell  of  the  calf  to  the  groin.     This  splint  is  split  on  the  side  or 


Fig.  475. — Expectant  method 
of  treating  fracture  of  the  patella. 
Anterior  view  of  apparatus  com- 
plete. The  padding  of  the  side 
splints  is  shown. 


Fig.  476.— Extent  of  flannel  bandage  to  knee, 
applied  after  all  immobilizing  apparatus  is  re- 
moved.    The  bandage  is  started  at  I. 


posteriorly  and  arranged  as  a  removable  dressing.     Proper  bath- 
ing is  facilitated.     This  enables  the  masseur  to  work. 

The  removable  splint  is  made  thus :  A  light  weight  plaster-of- 
Paris  roller  bandage  is  applied  to  the  properly  protected  leg  from 
above  the  ankle  to  the  groin.  It  is  split  in  the  median  line  its 
whole  length  before  the  plaster  has  quite  hardened.  It  is  sprung 
off  the  leg.     After  it  is  hard  a  narrow  strip  of  leather,  upon  which 


336  FRACTURES  OF  THE  PATELLA 

are  fastened  lacing  hooks,  is  stitched  to  each  cut  edge.  This  spHnt 
may  now  be  sprung  on  the  limb  and  laced  snugly  in  position.  A 
leather  splint  may  be  similar!}^  made  from  a  plaster  cast  and  mold 
of  the  limb.  As  soon  as  union  is  firm,  the  patient  should  be  up 
and  about  with  the  light  removable  fixation  splint  applied,  walking 
with  the  aid  of  crutches. 

Fixation  (prevention  of  flexion  and  extension)  on  walking  is  to 
be  maintained  for  at  least  six  months  after  the  injury.  Protecting 
the  knee  thus  when  walking  for  this  period  of  six  months  does  not 
preclude  active  movements  of  the  knee  when  not  bearing  weight 
upon  the  limb.     At  the  end  of  that  time  the  patient  may  be  al- 


Fig.  4  77. —Old  fracture  of  patella  ;  great  separation  of  fragments.  Condyles  of  the  femur 
are  prominent  in  between  fragments.  Leg  was  useful,  but  weak.  A,  The  lower  fragment ; 
B,  the  condyles  of  the  femur  ;   C,  the  upper  fragment. 


lowed  to  go  about  with  a  cane  and  a  snugly  fitting  roller  bandage 
(see  Fig.  476).  This  bandage  should  be  made  of  medium  weight 
flannel,  cut  straight  with  the  weave  and  not  on  the  bias.  The 
bandage  should  be  applied  from  the  middle  of  the  calf  of  the  leg 
to  the  middle  of  the  thigh  when  the  leg  is  completely  extended.  As 
the  patient  becomes  confident  of  his  strength,  the  cane  need  not 
be  carried.  Sudden  movements  are  to  be  avoided.  At  the  end  of 
eight  or  ten  months,  varying  with  the  individual  case,  all  support 
may  be  omitted  from  the  knee. 

The  Restoration  of  the  Function  of  the  Joint. — From  the  day  of  the 
injur}^  daily  massage  to  the  whole  limb  is  important.     It  maintains 


HXPKCTAXT    TKHATMKNT 


337 


the  muscles  in  good  lone.  It  prevents  adhesion  of  the  fragments  to 
the  tissues  about  the  condyles  of  the  femur,  a  not  uncommon 
cause  of  ankylosis  of  the  joint.  It  facilitates  the  absorption  of  the 
effusion  of  blood  and  synovial  fluid.  After  the  fourth  week  daily 
passive  motion  is  to  be  instituted:  at  first  ver>-  slight  indeed, 
barelv  two  or  three  degrees.  If  the  relative  position  of  the  frag- 
ments is  not  altered  perceptibly  by  this  passive  motion  and  lasting 
pain  is  absent,  it  may  be  persisted  in  with  regularly  increasing 


Fig.  478.— Case :  Fracture  of  the  patellae.     Moderate   separation  of  the   fragments  of  each 
knee-joint.    Useful  legs. 


amounts.  At  the  expiration  of  eight  or  ten  weeks  active  motion  at 
the  knee-joint  may  cautiously  be  allowed.  The  appearance  of 
persistent  and  increasing  tenderness,  sensitiveness,  or  pain,  and 
increasing  separation  of  the  fragments  are  the  indications  to  dimin- 
ish or  cease  passive  and  active  motions. 

Summary  of  the  Treatment  of  Fracture  of  the  Patella  by  the 
Expectant  or  Xonoperative  Method. — During  four  w-eeks  fixation 
of  the  knee,  elastic  compression,   douching,  massage,  the  thigh 


338 


FRACTURES   OF   THE   PATELLA 


flexed  slightly  on  pelvis,  the  leg  extended,  retentive  straps,  coapta- 
tion splints,  are  the  measures  employed.  At  the  fourth  or  sixth 
week,  remove  all  apparatus,  apply  removable  splint,  allow  walking 
with  crutches,  and  use  daily  passive  motion.  At  the  eighth  week, 
discard  crutches,  use  cane,  and  permit  limited  daily  active  motion. 
At  the  sixth  month,  discard  splint,  apply  flannel  bandages,  and  dis- 
card cane.  At  the  eighth  to  the  tenth  month,  remove  all  support. 
Open  Fracture  of  the  Patella. — This  is  a  Yery  serious  injury, 
because  one  of  the  largest  synovial  cavities  of  the  body  is  exposed 


Fig.  479. — Fracture  of  upper  third  of  patella,  showing  separation  of  fragments.     Tilting  of 
the  upper  fragment  through  rotation  upon  its  transverse  axis  (X-ray  tracing). 


to  infection.  It  is  safest  and  wisest  to  lay  open  the  knee-joint,  to 
thoroughly  irrigate  it  with  a  solution  of  corrosive  sublimate 
(i :  10,000),  and  then  with  a  sterilized  normal  salt  solution.  All 
blood-clots  should  be  carefully  wiped  away.  All  loosely  attached 
fragments  of  bone  should  be  removed.  Particular  attention  should 
be  paid  to  the  posterior  parts  of  the  joint,  behind  the  condyles  of 
the  femur.  It  will  be  found  convenient  in  cleaning  these  parts 
first  to  flush  the  joint  with  sterile  salt  solution  and  to  flex  and  to 
extend  the  knee.  All  parts  of  the  joint  posteriorly  are  thus  likely 
to  be  thoroughly   flushed.     The  fragments  should  be  approxi- 


PROGNOSIS    AFTlvK    ICXPKCTANT    TREATMENT 


339 


mated  and  sutured  by  some  absorbable  suture.  The  skin-wound 
should  be  closed.  The  knee-joint  should  be  immobilized  in  a  pos- 
terior wire  splint  and  side  splints  or  in  a  plaster-of-Paris  splint. 

Prognosis. — Ordinarily,  an  individual  should  not  follow  his 
occupation  for  about  six  weeks  to  two  months  after  a  fracture  of 
the  patella — i.  e.,  unless  the  occupation  can  be  conducted  with 
a  leg  held  stiffly  at  the  knee.  The  functional  usefulness  of  the 
limb  and  not  anatomical  considerations  should  be  the  chief  crite- 


Fig.  480. — Fracture  of  the  patella  in 
the  lower  third,  showing  tilting  of  lower 
fragment  through  rotation  on  its  trans- 
verse axis  (X-ray  tracing). 


Fig.  481. — Fracture  of  lower  edge  of 
patella.  Little  separation  of  fragments. 
Indirect  violence  (X-ray  tracing). 


rion  in  determining  the  result  following  fracture  of  the  patella. 
If  a  man  can  earn  his  living  as  before  the  accident  without  local 
discomfort  or  hindrance,  he  possesses  a  useful  limb.  It  makes 
little  difference  if  there  is  a  slight  separation  of  the  fragments  or  a 
suggestion  of  a  limp  or  slight  atrophy  of  the  thigh  and  calf  muscles ; 
these  conditions  are  all  to  be  accepted  as  part  of  the  irreparable 
damage,  and  are  trivial.  In  nonoperative  cases  the  union  is 
usually  fibrous,  although  it  may  be  bony.  The  interval  between 
the  fragments  may  amount  to  five  or  six  inches.     The  approxi- 


340 


FRACTURES    OF    THE    PATELLA 


mation  of  the  fragments  of  the  patella  is  not  evidence  of  strength, 
for  the  fibrous  bond  of  union  may  be  much  narrower  than  the  frac- 
tured surface  and  ver}'  thin,  and  thus  easily  ruptured.  The  use- 
fulness of  the  limb  after  fracture  of  the  patella  is  not  dependent 
upon  any  one  factor,  either  the  kind  of  union  or  the  extent  of  the 
separation  of  the  fragments  of  bone.  There  are  usually  no  adhe- 
sions of  the  upper  fragment  to  the  femur;  but  injury  to  the  bursa 
under  the  quadriceps  may  cause  troublesome  adhesions  upon  the 


Fig.  482. — Double  fracture  of  patella  without  great 
separation  of  fragments  (X-ray  tracing). 


Fig.  4S3. — Transverse  fracture  of 
patella,  showing  straps  in  position  to 
hold  fragments  (X-ray  tracing). 


anterior  surface  of  the  thigh.  Full  flexion  is  a  common  result, 
but  there  is  often  limitation  of  active  extension.  There  almost 
always  remains  a  little  joint  stiffness,  despite  both  massage  and 
active  and  passive  motion;  this,  unless  due  to  fibrous  adhesions, 
disappears  gradually.  The  majority  of  cases  of  fracture  of  the 
patella  under  careful  nonoperative  treatment  will  secure  a  useful 
limb.  A  patella  once  fractured  and  having  united  by  fibrous  or 
bony  union  may  be  broken  through  the  callus  of  the  healed  fracture 
or  in  an  entirely  different  fracture  from  the  first  break. 


RESITLTS    AFTHR    I'RACTliRE    OF    THIi    PATELLA  34 1 

Results  after  Fracture  of  the  Patella. — In  a  series  of  forty- 
seven  cases  of  fracture  of  the  patella  treated  at  the  Massachusetts 
General  Hospital,  occurring  between  the  ages  of  eleven  and  sixty- 
five  years,  four  were  over  fifty  years,  thirteen  were  under  twenty - 
five  years,  twenty-nine  were  between  twenty-five  and  forty-five 
years,  one  was  forty-seven  years  old;  practically,  a  young  adult 
series.  Of  this  series  of  forty-seven  cases  ten  were  treated  by  opera- 
tion and  the  remainder  by  the  expectant  method.  These  cases  are 
not  mentioned  in  this  connection  to  compare  methods  of  treatment, 
but  to  determine  the  condition  of  the  knee  a  long  time  after  the 


\ 
\ 
\ 
\ 
\ 
•      \ 
\ 
\ 
I 


I 
I 

Fig.  484. — Comminuted  stellate  fracture  of  patella  through  direct  violence  (X-ray  tracing) 


injur\'.  As  a  matter  of  fact,  there  appeared  no  greater  freedom 
from  the  symptoms  complained  of  among  the  cases  operated  on 
than  among  those  unoperated.  The  results,  as  carefully  recorded 
in  these  forty -seven  cases,  suggest  some  of  the  difficulties  that 
patients  experience  after  fracture  of  the  patella.  The  detailed 
reports  of  these  cases,  from  one  and  one-half  to  ten  and  one-half 
years  after  treatment  ceased,  show  that  about  twenty  have  as 
good  a  leg  as  before  the  accident.  The  remaining  twenty -seven 
cases  complain  of  limitation  of  motion  at  the  knee-joint,  that  the 
knee  creaks  in  walking,  that  it  feels  stiff,  aches,  and  burns  at  times. 
The  leg  is  said  to  be  weak,  and  is  troublesome  in  going  up  and 


342 


FRACTURES    OF    THE    PATELLA 


down  stairs — stepping  up  is  especially  difficult ;  kneeling  is  pain- 
ful ;  stepping  upon  irregular  surfaces  is  painful ;  running  with  the 
same  freedom  as  before  the  accident  is  impossible ;  the  knee  often 
gives  way  in  walking  and  causes  a  fall;  the  patient  can  not  jump 
as  before  the  accident,  and  walks  with  a  slight  limp.  Pain  is 
present  in  or  about  the  knee  in  damp  weather  and  after  unusual 
exertion. 


Fie^.  485. — Old  fracture  of  patella.  Much 
separation  of  fragments.  Small  nodules  of 
bone  seen  in  the  band  of  union  (X-ray  tracing). 


Fig.  486. — Old  fracture  of  patella. 
Wide  separation  of  fragments.  Dimp- 
ling of  skin.  A  useful  but  not  a  strong 
leg  (Massachusetts  General  Hospital, 
847.     X-ray  tracing). 


Operative  Interference  in  Recent  Closed  Fractures  of  the 
Patella. — In  deciding  whether  a  given  case  should  be  treated  by 
operation  or  not  the  following  considerations  should  be  carefully 
weighed :  A  closed  fracture  of  the  patella  does  not  in  itself  endan- 
ger life.  It  may  be  treated  by  the  conservative  method  without 
added  risk.  If  properly  treated,  the  result  will  ordinarily  be  satis- 
factory as  far  as  the  functional  usefulness  of  the  knee  is  concerned. 
The  operative  method  consumes  less  time  in  convalescence  and  an 


OPERATIVE    TRKATMIiNT 


343 


excellent  result  is  achieved,  but  operation  exposes  to  the  danger 
of  sepsis;  If  sepsis  results,  the  following  conditions  are  imminent : 
A  stiff  knee,  amputation  of  the  thigh,  and  possibly  death  from 


Quadriceps  tendon 


Upper  fragment  of  patella. 
Periosteum. 

Interposing  tissues. 
Lower  fragment  of  patella. 


Patellar  tend 


—  Joint  surface. 
Cartilage. 


Fig.  4S7.— Median  section  of  patella  and  tendons  (diagrammatic),  showing  interposition  of 
fascia  and  periosteal  shreds  between  the  fragments. 


Fig.  488.— Fracture  of  patella;  fragment  approximated  and  sutured  with  silver  wire.     Wire 
seen  in  situ  (X-ray  tracing.     C.  B.  Porter). 


septic  infection.  Whether  operation  shall  be  done  or  not,  there- 
fore, depends  upon  the  degree  of  safety  \vith  which  it  can  be  per- 
formed.    It  is  the  surest  method  of  securing  perfect  apposition 


344 


FRACTURES    OF   THE    PATELLA 


and  bony  union.  It  should  be  undertaken  only  by  surgeons  of 
exceptional  judgment  and  great  skill,  who  have  at  command 
skilled  assistants,  and  who  can  work  under  the  most  rigid  aseptic 
conditions.  The  acute  symptoms  should  be  allowed  to  subside 
before  operation.  The  tissues  require  time  to  recover  themselves 
from  the  acute  trauma.  The  operative  treatment  should  be  con- 
fined to  healthy  individuals  under  sixty  years  of  age ;  to  fractures 
with  a  separation  of  an  inch  or  more  of  the  bony  fragments  and 
extensive  lateral  fascial  tears  (the  fascial  tears  may  be  recognized 


Fig.  489.— Case:   Freshly  fractured  right  patella  sutured  with  chromicized  catgut.     Result 
after  eight  weeks.     Note  flexion  of  leg  to  a  right  angle  ;  line  of  incision  (Warren). 


by;joint  distention  and  locahzed  bulging) ;  to  cases  presenting  great 
joint  distention  that  does  not  disappear  quickly.  It  should  be 
seriously  considered  if  the  individual's  occupation  is  arduous  and 
necessitates  much  standing  or  walking.  The  patient  should  be 
informed  as  to  the  probable  outcome  by  the  two  methods  of  treat- 
ment. The  danger  to  life  and  limb  should  be  fairly  stated.  It 
should  be  remembered  that  the  power  of  extension  of  the  leg  is 
not  materially  limited  by  a  transverse  fracture  of  the  patella  in 
which  the  tearing  of  the  lateral  fascia  is  absent.     Only  in  direct 


OPKkATIVE    TREATMENT  345 

proportion  to  the  extent  of  the  lateral  fascial  tear  is  there  limita- 
tion of  the  power  of  extending  the  leg  upon  the  thigh.  In  open 
fractures,  in  rcfracture,  and  in  cases  of  impaired  function  from 
long  fibrous  union  or  from  adhesions  of  the  patella  or  from  badly 
united  patellaMuechanicalh- impeding  the  movements  of  the  joint, 
operation  is  always  indicated.  The  working-man  who  wants  to 
get  to  work  should,  under  the  conditions  previously  stated,  have 
his  patella  sutured,  for  he  will  go  to  work  quicker  and  have  a  better 
knee-joint  than  by  any  method  of  treatment. 

Method  of  Operation. — The  joint  and  the  fractured  bones  are  to 
be  thoroughly  exposed  by  a  transverse  or  longitudinal  incision. 
All  clots  should  be  thoroughly  washed  or  sponged  out.  Any  loose 
small  fragments  of  bone  should  be  removed.  In  almost  all  cases  a 
rather  dense  fascia  will  be  found  overlapping  the  broken  surfaces 
of  the  two  fragments  (especially  is  this  seen  in  a  transverse  frac- 
ture). These  bits  of  overlapping  tissue  or  curtains  of  tissue  should 
be  retracted  and  removed  or  utilized  in  suturing  the  fragments  (see 
Fig.  487).  Whether  silver  wire  is  employed  to  suture  the  bone 
directly  or  whether  an  absorbable  material  is  used  to  suture  the 
soft  parts  seems  of  little  consequence  as  long  as  all  fascial  tears  are 
sutured  and  the  bony  fragments  are  approximated  (see  Fig.  488). 
The  weight  of  opinion  to-day  is  in  favor  of  absorbable  sutures. 
Closure  of  the  joint  without  drainage  and  immobilization  in  the 
extended  position  followed  by  the  treatment  already  mentioned 
are  indicated  (see  Fig.  489). 

The  Restoration  of  the  Function  of  the  Joint  Following  the  Opera- 
tive Treatment. — After  suture  of  the  patella,  massage  and  gentle 
passive  motion  should  be  begun  at  the  end  of  two  weeks.  At  the 
end  of  three  weeks  the  patient  may  go  about  with  the  knee  pro- 
tected by  a  light  stiff  dressing.  After  about  six  weeks  to  two 
months  a  flannel  bandage  and  a  cane  will  be  all  the  protection 
needed  to  the  knee.  At  the  end  of  three  months  the  knee  should 
be  functionally  perfect. 


HhsU> 


CHAPTER  XIV 

FRACTURES  OF  THE  LEG 

Anatomy. — The  following  structures  may  be  palpated:  The 
internal  and  external  tuberosities  of  the  tilDia,  the  whole  of  the 
external  tuberosity  being  subcutaneous;  the  broad  anterior  and 


Fig.  490. — Middle  of  the  patella,  tubercle  of  the  tibia,  and  midpoint  between  the  malleoli  all 
lie  in  the  same  straight  line  as  the  leg  rests  naturally. 

inner  surface  of  the  tibia,  which  forms  the  shin,  downward  to  the 
internal  malleolus;  the  sharp  crest  of  the  tibia  throughout  its 
whole  length ;  the  head  of  the  fibula,  an  inch  below  the  top  of  the 

346 


ANATOMY    OF    THE    TIBIA    AND   FIBULA 


347 


tibia;  a  little  of  the  shaft  of  the  fibula  below  the  head  and  the  at- 
tachment of  the  biceps  tendon ;  the  lower  third  of  the  fibula  which 
is  subcutaneous.  The  tubercle  of  the  tibia  is  distinctly  felt  on  the 
anterior  surface  of  the  upper  end  of  the  tibia.     It  is  one  inch  from 


Fig.  491. — Fracture  of  the  tibia;  union 
with  displacement  forward  and  outward 
(Warren  Museum,  specimen  1140). 


Fig.  492. — Fracture  of  the  tibia  low 
down;  marked  outward  bowing;;  union 
(Warren  Museum,  specimen  1146). 


the  articular  surface,  and  marks  the  lowest  limit  of  the  upper 
epiphysis  of  the  tibia.  Into  it  is  inserted  the  patellar  tendon.  The 
shaft  of  the  tibia  arches  slightly  forward.  The  shaft  of  the  fibula 
arches  slightly  backward.  The  broad  inner  malleolus  is  higher 
than  the  outer  malleolus,  and  more  to  the  front  of  the  leg.     The 


348 


FRACTURES   OF   THE    LEG 


outer  malleolus  is  narrow.  The  posterior  edges  of  the  two  malle- 
oli are  in  about  the  same  plane.  The  anterior  edge  of  the  external 
malleolus  is  about  an  inch  behind  the  anterior  edge  of  the  internal 


Fig.  493. — Fracture  of  the  left  fibula 
near  the  lower  end  ;  united.  View  from 
outer    side   (Warren    Museum,    specimen 

1150). 


Fig.  494. —  Fracture  of  the  tip  of  the 
lower  end  of  the  left  fibula  ;  united.  View 
from  inner  side  (Warren  Museum,  speci- 
men 1151). 


Fig.  495. — Fracture  of  the  tibia  low  down  ;  displacement  of  the  upper  fragment  backward  ; 
union  (Warren  Museum,  specimen  7723). 


malleolus.  The  narrowest  part  and  the  weakest  place  in  the  tibia 
is  at  the  junction  of  the  lower  and  middle  thirds  of  the  bone.  In 
the  normal  leg  the  middle  of  the  patella,  the  tendon  of  the  patella, 


^iit 


o  i"  2 

1)  -  — 


349 


350 


FRACTURES    OF   THE)    LEG 


and  the  midpoint  of  the  ankle  are  in  the  same  straight  Hne  (see 
Fig.  490). 

General  Observations. — Fractures  of  the  tibia  and  fibula  mav 
occur  at  any  point,  depending  upon  the  seat  and  direction  of  the 
fracturing  force.  If  the  force  is  indirect,  the  fracture  of  the  two 
bones  will  be  at  different  levels.     If  the  fracture  is  high  up,  the 


Fig.  497. — Fracture  of  both  bones  of 
the  leg  ;  union  with  considerable  displace- 
in&UiU.cross  union  of  the  two  bones  (War- 
ren Museum,  specimen  5265). 


Fig.  498.— Fracture  of  both  bones  of 
the  leg;  displacement  of  upper  fragments 
downward  and  inward ;  union  (Warren 
Museum,  specimen  S303). 


knee-joint  may  be  involved  or  the  popliteal  vessels  and  peroneal 
nerve  may  be  implicated.  If  the  fracture  is  low  down,  the  ankle- 
joint  may  be  involved.  The  high  fracture  of  the  tibia  is  usually 
transverse.  The  low  fracture  of  the  tibia  is  usually  oblique.  The 
common  seat  of  fracture  is  at  about  the  junction  of  the  middle 
and  lower  thirds  of  the  leg.     The  line  of  the  fracture  is  an  oblique 


METHOD   OF   EXAMINATION  35 1 

one,  extending  from  above  and  bcliiiid  downward  and  forward 
through  the  tibia.  The  llbula  is  fraetnred  a  Httle  higher  than  the 
tibia.  If  the  force  is  considerable  and  the  sharpness  of  the  frag- 
ments great,  the  overlying  skin  may  be  lacerated,  an  open  or  in- 
fected fracture  resulting.  The  upper  and  lower  epiphyses  of  the 
tibia  may  be  separated;  these  are,  however,  rare  injuries.  The 
tibia  and  fibula  may  be  fractured  separately.  In  such  cases  the 
unbroken  bone  serves  as  a  splint  for  the  fractured  one.  The  dis- 
placement in  these  latter  fractures  is  slight. 

It  is  not  very  unusual  to  find  a  starting  of  the  upper  epiphysis  of 


Fig.  499. — Method  of  measuring  the  length  of  the  tibia    rom  the  internal  tuberosity  to  the 

internal  malleolus. 


the  tibia  as  illustrated  in  figure  496.  Dr.  Robert  Osgood  has 
demonstrated  recentlv  that  manv  apparentlv  trivial  injuries  to  the 
region  of  the  tubercle  of  the  tibia  are  in  realitv  partial  separations, 
with  or  without  some  displacement  of  the  tongue-shaped  portion 
of  the  upper  epiphysis  of  the  tibia,  or  actual  separation  of  an  inde- 
pendent bony  center  for  the  tubercle  of  the  tibia.  Clinicalh^  slight 
swelling  and  tenderness  in  the  region  of  the  tibial  tubercle  and  pain 
upon  extension  are  the  chief  signs. 

Examination  of  a  Fractured  Leg. — It  is  sometimes  extremely 
difficult  to  detect  a  fracture  of  the  leg.  It  is,  therefore,  important 
that  a  systematic  examination  should  be  made  immediatelv  after 


352 


FRACTURES    OF    THE    LEG 


the  injun.-.  Deformitv  As'ill  ordinarih"  be  apparent  upon  inspec- 
tion (see  Fig.  501  j.  Gentle  manipulation  will  suffice  to  satisfy  one 
of  the  existence  of  a  fracture,  particularly  if  both  bones  are  broken. 
An  open  fracture  will  be  eA-ident  if  a  wound  exists  in  the  skin  near 
the  seat  of  fracture.  In  taking  hold  of  the  leg  for  examination  or 
for  moving  the  leg  it  should  not  be  grasped  lightly  bv  a  few  fingers 
but  bv  the  whole  hand  firmly,  as  one  grasps  an  ax  handle  in  chop- 


'i^^-^ 


Fig.  500. — Fracture  of  both  bones  of  the  left  leg.  Comparative  height  of  knees  to  show 
shortening  of  leg.  The  patient  is  sitting  with  knees  ilexed  to  a  right  angle  (after  Van 
Lennep). 

ping  wood;  not  as  one  lifts  a  lead-pencil  from  the  table.  The  leg 
should  be  so  raised  in  naaking  the  examination  that  there  is  abso- 
lutely no  risk  of  converting  the  closed  fracture  into  an  open  one. 
In  order  to  guard  against  this  the  assistant  should  grasp  the  foot 

at  the  ankle  and  make  gentle  but  strong  traction  in  the  long  axis 
of  the  leg  as  the  whole  leg  is  raised.  This  care  in  examination  will 
cause  the  patient  a  minimum  amount  of  pain.  Crepitus  is  not  the 
onlv  thing  that  is  to  be  sought  at  the  examination.     The  freedom 


SYMPTOMS 


353 


of  anv  abnormal  moMlilv  should  be  noticed,  as  well  as  the  direc- 
tion of  the  motion,  the  ease  with  which  reduction  is  possible,  and 
the  liability  to  recurrence  of  the  deformity.  If  there  is  any  doubt 
as  to  the  seat  or  extent  of  the  fracture,  the  examination  should  be 
made  with  the  assistance  of  an  anesthetic.  The  temporary  dress- 
ing may  be  applied  at  this  time.  The  bones  should  be  palpated. 
While  an  assistant  steadies  the  knee-joint  the  surgeon,  grasping 
the  lower  part  of  the  leg,  attempts  motion  in  each  direction.  vSim- 
ply  raising  the  leg  and  attempting  motion  in  an  anteroposterior 
direction  is  not  sufficient ;  a  fracture  of  the  tibia,  if  transverse, 
might  remain  completely  locked  except  upon  lateral  movement. 
The  tibia  should  be  measured  (see  Fig.  499)  from  the  knee-joint 
line,  at  the  upper  border  of  the  internal  tuberosity,  to  the  lower 


1\IS 


>f>\ 


Fig.  501. — Case:  Fresh  fracture  of  the  leg  (both  bones).  Characteristic  deforrnity.  Note 
normal  position  of  patella,  with  the  foot  lying  on  its  outer  side.  Prominence  of  upper  frag- 
ment. Compare  this  with  figure  391  of  a  fracture  of  the  thigh  in  which  the  patella  does  not 
look  upward. 


edge  of  the  internal  malleolus  to  determine  shortening. 


Shorten- 


ing of  the  leg  may  be  roughly  estimated  after  union  of  the  bones  by 
comparing  the  height  of  the  two  knees  while  the  soles  of  the  feet 
rest  upon  the  floor  (see  Fig.  500).  The  measurement  should  be 
compared  with  that  of  the  uninjured  tibia.  It  is  often  difficult 
in  fractures  near  the  ankle  to  palpate  the  internal  malleolus,  on 
account  of  swelling.  Deep  pressure  with  the  thumb  will  detect  it. 
Inquiry  should  be  made  as  to  whether  either  tibia  has  ever  been 
fractured  previously.  The  pulse  should  be  felt  for  in  the  posterior 
tibial  and  dorsalis  pedis  arteries  to  be  sure  that  the  large  vessels 
of  the  leg  are  intact. 

Symptoms. — Ordinarily,  the  presence  of  pain,  deformity,  abnor- 
mal mobility,  crepitus,  and  loss  of  use  of  the  leg  will  be  the  evi- 
23 


354 


FRACTURES   OF   THE   LEG 


dences  of  fracture.  If  the  fracture  is  of  the  tibia  or  hbula  alone 
and  transverse  without  much  displacement,  localized  tenderness 
upon  pressure  and  swelling  will  be  the  only  signs.     It  is  important 


Fig.  502. — Fracture  of  the  tibia,  oblique  and  high  up.     Almost  no  displacement  (Massachusetts 
General  Hospital,  1235.     X-ray  tracing). 


Patella. 


Tibia. 


Fibula. 


Fig-  503- — Fracture  of  the  external  tuberosity  of  the  tibia  (Massachusetts  General  Hospital, 

1242.     X-ray  tracing). 


to  remember  the  backward  bowing  of  the  fibula  iiL  attempting  to 

localize  by  palpation  the  tender  point  of  the  fracture  of  that  bone. 

The  deformity  is  due  to  the  displacement  of  the  upper  fragment 


SYMPTOMS 


355 


forward  and  of  the  lower  fragment  upward  and  backward.  If  the 
fracture  is  oblique,  this  displacement  will  be  considerable.  The 
lower  fragment  is  often  rotated  upon  its  longitudinal  axis,  so  that 
the  foot  rests  upon  its  side,  while  the  upper  fragment  remains  un- 
disturbed by  rotation,  the  patella  looking  directly  upward  (see 
Fig.  501). 

The  swelling  will  var\\  It  may  be  extremely  slight  and  limited 
to  the  seat  of  the  fracture  or  it  may  extend  over  the  entire  leg.  The 
maximum  swelling  of  the  leg  is  usually  reached  three  or  four  days 


Fig.  504. — Longitudinal  Assuring  of 
tibia  from  blasting  accident.  Front  view 
(X-ray  tracing). 


Fig.  505. — Longitudinal  Assuring  of 
tibia  from  blasting  accident.  Lateral  view. 
Same  as  figure  504  (X-ray  tracing). 


after  the  accident.  If  the  fracture  was  caused  by  direct  violence 
and  the  fragments  of  bone  are  sharp,  the  soft  parts  will  be  dam- 
aged and  the  resulting  hemorrhage  and  swelHng  will  be  ver\'  con- 
siderable. 

Ecchymosis  of  the  skin  appears  in  from  twentv-four  to  forty- 
eight  hours  after  the  accident ;  it  may  extend  over  the  whole  leg. 
Ecchymosis Jmm^a  sprain  is  localized  more  or  less  about  the  seat 
ofjhe  sprain;  that  from  a  fracture  is  often  extensive.  Blebs  or 
vesicles  may  appear  near  the  fracture  during  the  fiirst  week  if  the 


356 


FRACTURES    OF    THE    LEG 


swelling  is  great.     It  is  necessary*  to  exercise  great  caution  in  the 
care  of  these  blebs,  that  they  do  not  become  infected. 

Fracture  of  the  shaft  of  the  fibula  may  be  very  obscure,  but 
pressure  upon  the  fibula  toward  the  tibia  will  elicit  pain  and  crepi- 
tus. In  separation  of  the  lower  epiphysis  of  the  tibia  the  preserva- 
tio.n^fjthe^normal  relations  between  the  malleoli  is  of  considerable 
diagnostic  importance. 


Fig.  5o5. — Oblique  fracture  of  the  tibia 
low  down ,  and  oblique  fracture  of  the  fibula 
at  its  middle  (X-ray  tracing). 


Fig.  507. — Fracture  of  both  bones  of 
the  leg  at  the  middle;  slightly  spiral  of 
tibia  (Massachusetts  General  Hospital, 
1134.     X-ray  tracing). 


Treatment. — For  purposes  of  treatment  fractures  of  the  leg  are 
arranged  into  scA^eral  distinct  groups — viz. : 

1.  Fractures  with  little  or  no  swelling  or  displacement. 

2.  Fractures  with  considerable  swelling. 

3.  Fractures  with  a  displacement  of  fragments  difficult  to  hold 
corrected. 

4.  Open  fractures. 

The  indications  to  be  met  bv  treatment  in  each  of  these  groups 


TREATMENT 


357 


are  corrcclion  of  dcfoniiily,  inimobilization  of  fragments,  and  res- 
toration of  the  limb  to  its  normal  condition. 

Fractures  with  Little  or  No  Displacement  or  Swelling. — Fractures 
of  the  tibia  alone  or  the  fibula  alone  are  properly  placed  in  this 
group.  Fractures  of  both  bones  occasionally  occur  with  little  or 
no  displacement  and  with  but  a  trifling  amount  of  swelling.     In 


H\i^m 


^  NT:-/ 


Fig.  508. — Oblique  fracture  of  both 
bones  of  the  leg.  Displacement  of  the 
upper  fragments  in  the  same  inward  direc- 
tion (Massachusetts  General  Hospital,  749. 
X-ray  tracing). 


Fig.  509. — Transverse  fracture  of  both 
bones  of  the  leg  at  the  middle;  slight 
displacement  and  considerable  bowing 
(Massachusetts  General  Hospital,  1215. 
X-ray  tracing). 


these  cases  the  le^  should  be  elevated  for  ten  minutes  in  order  to 


lessen  the  swelling.  The  foot,  leg,  and  lower  thigh  are  then 
bathed  with  soap  and  water,  and  thoroughly  dried  and  powdered. 
The  leg  being  properly  protected,  a  light  plaster-of -Paris  roller 
bandage  is  applied  from  the  toes  to  the  middle  of  the  thigh.  (See 
Details  of  Plaster  Work.)  Thejeg  jsjo  be^£LelevatedJor^the 
first  week  bv  at  least  t\yii_,ox..tlu:&fc,,piUGm:;a.    If  good  judgment  is 


358 


FRACTURES    OF   THE   LEG 


exercised  in  the  subsequent  care  of  the  case,  the  placing  of  such  a 
fracture,  as  previously  indicated,  immediately  in  a  plaster-of- Paris 
splint  is  attended  b}'  no  risk.  The  danger  lies  in  too  great  pressure 
upon  the  circulation,  caused  by  the  increasing  swelling  of  the  leg 
within  the  unyielding  plaster  splint.  Pressure  sores  and  gangrene 
are  liable  to  result.  In  applying  the  splint  a  liberal  amount  of 
sheet  wadding  should  be  used.  The  condition  of  the  circulation 
should  be  noted  immediately  after  the  application  of  the  splint  and 
at  regular  intervals  thereafter  until  all  danger  from  undue  pressure 
has  ceased.     Evidences  of  Jtoo_great  pressure  are  persistent  or 


Fig.  510. — Double  fracture  of  the  tibia. 
Single  fractureof  the  fibula  (Massachusetts 
General  Hospital,  1055.     X-ray  tracing). 


Fig.  511. — Fracture  of  the  fibula  with- 
out injury  to  the  tibia  (Massachusetts 
General  Hospital,  1230.    X-ray  tracing). 


increasing  swelling  of  the  toes,  blueness  of  the  toes,  and  pain.  It 
is  well,  in  order  to  avoid  undue  pressure  upon  the  leg,  to  split  the 
plaster  the  entire  length  of  the  splint  before  it  has  quite  hardened. 
The  splint  loses  by  this  procedure  none  of  its  immobilizing  quali- 
ties, for  it  can  be  bandaged  or  strapped  tightly  together  again. 
Too  great  pressure  upon  the  circulation  can  then  be  immediately 
relieved  by  loosening  the  retaining  straps  or  bandage  and  thus 
opening  the  splint.  After  the  splint  has  been  on  the  leg  for  about 
a  week  and  a  half  or  two  weeks,  the  swelHng  having  begun  to  sub- 
side,  the  plaster  splint  will  become  loose  and  will  cease  to  hold  the 


TREATMENT 


359 


fragments  ririiil>-.  Unless  a  new  and  snug  splint  is  now  applied,  it 
will  be  necessary  to  cut  out  a  strip  of  plaster  an  inch  or  more  wide 
from  the  old  splint  to  admit  of  tightening.  Duringf  the  changing 
of  the  plaster  splint  the  log  should  be  steadied  bv  an  assistant  while 
it  is  thoroughly  washed  with  so^p  and  yator  and  bathed  with 
alcohol. 

Fractures  with  Considerable  Immediate  Spelling. — Many  fractures 
are  not  seen  by  the  surgeon  until  two  or  three  hours  after  they 
have  occurred,  when  considerable  swelling  is  present.     Associated 


12. — Fracture  of  the  fibula  low 
down  without  fracture  of  the  tibia  (X-ray 
tracitig). 


Fig.  513. — Oblique  fracture  of  both 
bones  of  the  leg  low  down.  Fracture 
difficult  to  hold  in  good  position  (Massa- 
chusetts General  Hospital,  1024.  X-ray 
tracing). 


with  such  primary  swelling  there  will  be  laceration  of  the  soft  parts 
and  possible  extensive  injur}'  to  the  bone.  Blebs  filled  with  clear  or 
bloody  serum  may  be  present  about  the  seat  of  fracture.  These 
should  be  evacuated  after  the  part  has  been  rendered  surgically 
clean  by  washing  with  soap  and  water  and  corrosive  sublimate 
solution,  and  then  dressed  with  a  drs'  antiseptic  powder,  powdered 
dermatol,  or  aristol.  Infection  _.may  .^ take^  2lace_th.iaasb  biph.'i ■ 
Ver\'  great  care  should  be  exercised  in  their  treatment.  Obvi- 
ously, it  is  unwise  immediately  to  apply  a  plaster-of-Paris  sphnt  to 
cases  in  which  there  are  many  blebs  and  much  swelling.     The 


36o 


FRACTURES    OF    THE    LEG 


swelling  of  the  leg  may  become  so_  great^that  the  life  of  the  limb 
ma^be  at  5take,  the  danger  from  impending  gangrene  becoming 
imminent.  In^such  cases  the  skin  of  the  leg  becomes  tense  and 
shiny,  the  leg  feels  hard  and  board-like,  pain  may  be  extreme,  and 
the  toes  and  foot  become  slightly  blue.  The  hemorrhage,  being 
confined  beneath  the  fascia  and  skin,  causes  pressure  upon  the 


Fig.  514. — Fracture  of  both  bones  of 
the  leg  from  bullet-wound.  Characteristic 
comminution  of  the  bones.  Bullet  not  re- 
moved. Recovery  with  a  useful  leg  (X-ray 
tracing)  (Warren). 


\ 

Fig.  515. — Transverse  fracture  of  the 
tibia,  high.  Direct  violence.  Great  swell- 
ing of  leg.  Threatening  gangrene.  Free 
incisions.  Leg  saved.  Result  good.  Same 
case  as  figure  516  (Massachusetts  General 
Hospital,  1064.     X-ray  tracing)  (Scudder). 


circulation.  The  circulation  in  the  leg  is  thus  impeded.  Under 
such  circumstances  operation  is  necessary-  in  order  to  relieve  ten- 
sion and  to  check  hemorrhage.  Incisions  in  the  long  axis  of  the 
limb  through  skin  and  fascia  will  be  followed  by  a  rapid  decrease 
in  the  swelling  of  the  leg  and  a  cessation  of  the  pain.  After  inci- 
sion^the  bleeding  vessels  found  should  be  ligated.     The  bones  may 


TREATMENT 


361 


be  sutured  at  this  tiiiie  if  it  is  thought  wise.  If  these  wounds 
remain  aseptic,  they  may  be  closed  after  a  few  days  by  suture  or 
niav  be  allowed  to  heal  openly.  This  method  of  treatment  will 
usually  result  in  saving  the  leg  (see  Figs.  515,  516).  If  the  circu- 
lation  does  not  return  and  gangrene  is  imminent,  immediate  am- 


liJjW 


Fig.  516. — Case  :  Closed  fracture  of  the  left  tibia.  Hematoma.  Imijairnieiit  of  the  circu- 
lation. Free  incisions.  Evacuation  of  blood.  Relief  of  pressure.  Leg  saved.  Recovery 
(Scudder). 


r 

/^H 

■ 

^1% 

-Fracture  of  the  leg.     Temporary  or  emergency  dressing.     Application  of  the  pillow 
with  straps.     Open  end  of  the  pillow-case  at  the  foot. 


putation  of  the  limb  well  above  the  fracture  at  the,lower^Q£,ffljxldk 
third  of  the  thigh  is  the  onlv  Drocedure.  Traumatic  gangrene  is 
often  rapidly  followed  by  general  septic  infection.  It  is  best  to 
use  a  temporary-  dressing  in  cases  in  which  there  is  great  initial 
swelling  of  the  leg. 


362 


FRACTURES    OF   THE    LEG 


The  Temporary  Dressing. — The  Pillow  and  vSide  Splints. — The 
leg  is  placed  on  a  pillow  covered  with  a  pillow-case;  straps  are 
placed  under  the  pillow  and  drawn  snugly  up  about  the  leg  (see 
I^i&-  517)-  The  edges  of  the  pillow  are  rolled  in  against  the  leg  for 
firmness.  Narrowly  folded  towels  are  placed  between  the  leg  and 
the  straps.  The  straps  are  then  drawn  tighter.  The  open  end  of 
the  pillow-case  is  folded  and  pinned  under  the  sole  of  the  foot. 


1^ 

■i 

M 

1 

1 

1 

1 

1 

""     ""'        ^" 

Fig.  518. — Fracture  of  the  leg 


Pillow  and  side  splints  with  straps  and  towels.     Compare 
figure  519. 


-Fracture  of  the  leg.     Temporary  or  emergency  dressing, 
straps.     Pillow  held  by  shield-pins. 


Pillow,  side  splintF,  and 


// 


Three  pieces  of  splint  wood  are  introduced  between  the  pillojwand 
straps — one  is  slipped  underneath  and  one  upon  each  side  of  the 
pillow.  The  pillow  thus  serves  as  a  padding  for  the  box  formed 
by  the  splint  wood  fsee  Fig.  518).  Ice-bags  niay  be  conveniently 
placec^alang  the  anterior  surface  of  the  leg  Ijctween  tlie  edges  of 
the  pillow.  They  relieve  pain  and  are  said  to  check  hemorrhage 
immediately  after  the  fracture.  If  greater  security  is  thought 
necessary,  the  pillow-case,  instead  of  having  its  sides  rolled  in, 


TREATMENT 


363 


may  be  pinned  with  shield-pins  up  over  the  anterior  surface  of  the 
leg  (see  Fig.  519). 

This  temporary  dressing  is  left  in  place  for  a  week  or  a  week  and  a 


Fig.  520.— Diagram  of  oblique  fracture  of  the  leg.    Displacement  upward  and  forward  of  the 

lower  fragment. 


Fig.  521. — Diagram  illustrating  a  frequent  method  of  apparently  correcting  the  displacement, 
which  results  in  producing  a  backward  bowing. 


Fig.  522. — Diagram  illustrating  the  pioper  direction  in  which,  combined  with  traction,  force 
should  be  exerted  in  order  to  correct  the  displacement. 


half.  The  swelling  will  then  have  partly  subsided.  If  at  this  time 
there  is  little  or  no  swelling  and  the  displacement  is  slight,  a  plaster- 
of-Paris  splint  may  be  apphed  as  a  permanent  dressing;  it  is  split 


364 


FRACTURES    OF    THE    EEG 


or  not  as  circumstances  indicate.  If,  on  the  other  hand,  at  the  end 
of  a  week  or  a  week  and  a  half  it  is  desired  to  have  the  fracture  open 
to  inspection  and  more  directly  accessible  and  under  the  eye  of  the 
surgeon,  then  the  posterior  wire  and  side  splints  should  be  applied. 
The  Permanent  Dressing  for  Fracture  of  the  Leg. — Several  im- 
portantthings  are  to  be  kept  constantly  in  mind  in  placing  a  frac- 
tured  leg  in  a  permanent  splint.  They  are  as  follows :  The  aline- 
nient  of  the  bones  of  the  leg  is  to  be  maintained ;  rotation  of  either 
fragment  upon  its  long  axis  is  to  be  avoided ;  the  foot  is  to  be  kept 
extended  to  a  right  angle  with  the  leg;  lateral  deviation  is  to  be 
avoided ;  the  inner  side  of  the  great  toe,  the  middle  of  the  patella, 
and  the  anterior  superior  spine_  of  the  ilium  should  be  in  one 
straight  line ;  anteroposterior  deformity  is  to  be  avoided  (the  con- 


Fig.  523. — Padding  the  Cabot  po<iterior  wire  splint.     Applying  slieet  wadding 
and  proportions  of  the  Cabot  splint  are  apparent. 


The  shape 


vexity  of  this  curve  of  deformity  is  usually  backward;  it  is  a 
hyperextension  of  the  leg  at  the  seat  of  fracture)  (see  Figs.  520- 
522) ;  frequent  measurements  and  inspection  of  the  leg  should  be 
made;  inspection  should  be  made  not  only  from  the  front,  but 
laterally  as  well;  readjustment  of  apparatus  is  necessitated  by 
changes  in  the  position  of  the  bones. 

The  Posterior  Wire  and  vSide  vSplints. — The  posterior  wire  or 
Cabot  splint  is  made  of  iron  wire  the  size  round  of  an  ordinary  lead- 
pencil  (see  Fig.  523).  It  is  applied  to  the  back  of  the  foot,  leg,  and 
thigh,  extending  from  just  beyond  the  tips  of  the  toes  to  above  the 
middle  of  the  thigh.  It  is  narrow  at  the  heel  and  broad  enough 
above  to  permit  the  thigh  to  rest  comfortably  upon  it.  The  foot- 
piece  is  at  right  angles  to  the  leg. 


TKEATMIvNT 


365 


Haviiii::  at  liaiul  tlif  iron  wire  the  size  of  an  ordinary  lead-pencil, 
this  splint  can  be  ciuickly  and  easily  made  Ijy  means  of  a  vise  for 
holding  the  wire,  and  a  wrench  for  grasping  the  wire  while  bending 
it.  The  two  free  ends  of  the  wire  of  the  splint  may  be  held  firmly 
together  by  having  them  overlap  and  binding  them  together  with 


■ 

J 

i 

s--„.      .          _^| 

Fig.  524. — Padding  the  Cabot  posterior  wire  splint:  (i)  With  sheet-wadding  (see  Fig. 
523;  (2)  w^ith  a  cotton  roller  around  the  wire,  and  (3)  around  both  wires,  to  form  a  back  to 
the  splint. 


small-sized  copper-wire.     These  free  ends  may,  of  course,  be  held 
by  solder. 

The  Covering  of  the  Posterior  Wire  Splint. — The  wire  is  wound 
first  with  a  roller  of  sheet  wadding,  then  with  a  cotton  roller,  and 
finally  a  cotton  roller  bandage  is  wound  about  both  sides  of  the 
splint  so  as  to  make  a  posterior  surface  upon  which  the  leg  may 
rest  (see  Figs.  523,  524,  525). 


366  FRACTURES   OF   THE   LEG 

The  side  splints  of  wood  (see  Fig.  526)  should  be  about  four 
inches  wide,  and  long  enough  to  extend  from  the  foot-piece  to  the 
top  of  the  splint.  The  side  splints  may  be  covered  with  sheet 
wadding  and  cotton  cloth,  as  seen  in  the  figure. 

Care  of  the  Heel. — If  but  slight  pressure  is  maintained, uppn  the 
heel  even  for  a  few  days,  a  pressure  sore  will  develop.  This  is 
liable  to  increase  to  a  considerable  size.  It  is  very  slow  in  healing. 
Many  weeks  after  the  fracture  of  the  leg  has  united  the  pressure 
sore  may  be  open.  It  is,  therefore,  of  verv  great  importance  to 
prevent  pressure  upon  the  heel  during  the  treatment  of  fractures 
of  the  lower  extremity  associated  with  dorsal  decubitus.  There 
are  four  methods  of  avoiding  pressure  on  the  heel.  Position  will 
assist  materially.     The  position  of  the  foot  largely  determines  the 


Fig.  525. — The  Cabot  posterior  wire  splint  padded  completely.     Note  the  foot-pad  of  paste- 
board covered  bj-  cotton-cloth  pinned  to  the  foot-piece  of  the  splint  for  greater  security. 


amount  of  pressure  falling  on  the  heel.  When  the  foot  rests 
naturally,  it  is  in  the  position  of  slight  plantar  flexion.  The  heel 
presses  firmly  upon  the  splint  (see  Fig.  527).  A  large  part  of  the 
weight  of  the  leg  thus  falls  upon  the  heel.  When  the  foot  is  ex- 
tended to  a  right  angle  with  the  leg,  the  pressure  upon  the  heel  is, 
in  a  large  measure,  removed  (see  Fig.  528).  Therefore,  in  putting 
up  fractures  of  the  leg  the  right-angle  position  is  the  desirable  one. 
Padding  above  the  heel  is  of  service.  The  ring  or  doughnut  pad 
around  the  heel  is  sometimes  efficient.  Slinging  the  foot  by  adhe- 
sive straps  applied  to  the  sides  of  the  heel  and  foot  and  fastened 
to  the  foot-piece  of  the  splint  is  a  very  satisfactory  method  of  re- 
moving pressure  from  the  point  of  the  heel  (see  Fig.  529). 

The  Padding  of  the  Posterior  Wire  Splint  for  the  Reception  of 


THE   PADDING    OF   THE    POSTERIOR   SPLINT  367 

the  Lower  Extremity. — Regard  should  be  luid  for  the  natural 
curves  of  the  leg  and  thigh  posteriorly  (see  Fig.  528).  Above  the 
heel,  behind  the  knee,  and  below  the  buttock  are  distinct  hollows, 
at  which  places  the  padding,  as  indicated  in  the  illustration,  should 
be  thicker  than  at  other  points.  Regard  should  likewise  be  had  for 
the  natural  lateral  curves  of  both  thigh  and  leg.     Just  below  the 


Fig.  526.— Side  splint  of  splint  wood  (3).     Method  of  padding:  (i)  With  sheet-wadding;  (2) 
with  cotton  cloth  ;  (4)  pinned  in  place,  and  then  (5)  stitched. 


malleoli,  above  the  ankle,  below  the  knee,  and  above  the  knee  are 
distinct  hollows  that  Avill  require  more  padding  than  elsewhere  on 
the  sides  of  the  limb  (see  Fig.  530).  The  more  carefully  the  splint 
is  padded,  the  more  nearly  perfect  will  be  the  result  of  treatment 
and  the  greater  will  be  the  comfort  of  the  patient. 

The  leg  is  to  be  placed  upon  the  posterior  wire  splint,  so  padded 


368 


FRACTURES   OF   THE   LEG 


posteriorly  that  it  rests  naturally  and  comfortably.  The  foot 
should  be  placed  at  a  right  angle,  drawn  down  snugly  to  the  foot- 
piece,  and  steadied  by  adhesive-plaster  straps  carried  around  the 
foot  and  splint  in  a  figure-of-eight  bandage  (see  Figs.  532,  533). 
The  side  splints,  so  padded  with  pillow-cases  or  towels  as  to  bring 
suitable  pressure  upon  the  leg  and  thigh,  are  apphed  and  held  in 
position  by  straps  and  buckles  (see  Fig.  533).  This  splint  immob- 
ilizes the  knee-  and  ankle-joints  and  the  fractured  bones.     The 


Fig.  527.— Normal  leg  with  foot  flexed,  showing  that  the  heel  rests  heavily  on  the  table  (see 

Fig.  528). 


Pig.  528.— Posterior  outline  of  the  normal  leg,  suggesting  the  necessary  padding  to  be 
used  on  the  Cabot  splint.  When  the  foot  is  at  a  right  angle  with  the  leg,  the  heel  rests  lightly 
on  the  table. 


re gion  i)f_jthe_f racture  is  open  to  inspection  anteriorly.  Lateral 
inspection  is  facilitated  by  loosening  the  straps  and  lowering  the 
side  splints.  Any  deviation  from  the  normal  lines  of  the  leg  can 
be  adjusted  easily.  Atjhe  end  of  three  weeks,  when  the  fracture  is 
uniting  and  the  callus  is  still  soft,  the  leg  should  be  rcnicn-ed  from 
the  splint  and  examined  carefully  from  the  front,  from  the  back, 
and  laterahy  for  any  deviation  from  the  normal.  If  any  deviation 
is  discovered,  it  should  be  corrected  and  the  leg  put  again  into  a 
posterior  wire  spHnt  or  into  a  removable  plaster-of-Paris  sphnt. 


TREATMENT 


369 


The  first  night  after  pulling  up  Ihc  fracture  the  patient  will 
probably  be  most  uncomfortable.  The  new  and  restrained  posi- 
tion, the  after-eflfect  of  the  anesthetic  if  one  has  been  used,  the 
points  of  undue  pressure  yet  to  be  adjusted,  the  itching  of  the  skin, 
the  inability  to  move  about,  the  necessity  of  lying  in  one  position, 
actual  pain  at  the  seat  of  the  fracture — all  combine  to  make  life 
miserable.  It  will  be  a  wise  precaution  on  the  part  of  the  attend- 
ant if  a  little  morphin  is  administered  subcutaneously  this  first 


Fig.  529. — Method  of  supporting  the  foot  in  fractures  of  the  leg  when  using  a  posterior  splint 
a,  Padding  beneath  tendo  Achillis  ;  6,  ring  under  heel ;  c,  sling  of  adhesive  plaster. 


night,  as  patient,  nurse,  and  physician  will  rest  better.  After  the 
first  night  there  will,  under  ordinary  circumstances,  be  no  especial 
difficulty.  After  the  plaster  splint  is  applied  the  Smith  anterior 
wire  splint  attached  to  the  anterior  surface  of  the  thigh,  leg,  and 
dorsum  of  the  foot  often  will  enable  the  leg  to  be  slung  just  so  as  to 
clear  the  bed.  This  position  is  one  of  considerable  comfort.  The 
patient  is  enabled  to  move  in  bed  a  little  and  to  change  his  position 
without  disturbing  the  fracture.  This  anterior  wire  splint  is  made, 
24 


370 


FRACTURES   OF   THE   LEG 


like  the  Cabot  posterior  wire  splint,  of  iron  wire,  but  is  fitted  to 
the  anterior  surface  of  the  foot,  leg,  and  thigh  (see  Fig.  531). 

Fractures  Difficult  to  Hold  Reduced. — These  are  usually  oblique 
fractures  of  the  tibia,  occurring  most  often  in  the  lower  half  of  the 
bone.  The  nearer  to  the  ankle-joint  the  fracture  is,  the  greater  is 
the  likelihood  of  a  displacement  which  is  hard  to  hold  reduced. 


Fig.  530.— Fractures  ot  the  leg.     Cabot  posterior  wire  splint  and  side  splints,  showing  the 
space  to  be  padded  on  each  side  of  the  leg  and  thigh. 


The  contraction  of  the  quadriceps  extensor  tends  to  pull  the  upper 
fragment  forward,  the  contraction  of  the  gastrocnemius  tends  to 
pull  the  lower  fragment  backward  and  upward.  The  obliquity 
of  the  fracture  and  the  action  of  these  two  groups  of  powerful 
muscles  make  it  almost  an  impossibility  to  hold  these  fractures 
reduced.     It  is  often,  even  under  an  anesthetic,  impossible  to  cor- 


Suspension    At  the 
hooks.        pelvis. 


F'g-  53'- — T^he  anterior  wire  suspensory  apparatus  of  N.  R.  Smith.  This  splint  is  applied 
to  the  anterior  surfaces  of  the  padded  foot,  leg,  thigh,  and  hip.  The  splint  is  fixed  to  the  leg 
by  a  bandage.  The  splint  is  intended  to  immobilize  the  leg  and  at  the  same  time  to  suspend 
it,  permitting  motion  at  the  hip,  and  to  secure  extension  upon  the  distal  fragments. 


Fig-  532. — Fracture  of  the  leg.    Cabot  posterior  wire  splint  padded  properly  according  to  the 
curves  of  the  normal  leg.    Note  that  the  heel  is  free  from  the  splint  (see  Fig.  528). 


Fig.  533. — Fracture  of  the  leg.     Cabot  posterior  wire  splint,  side  and  posterior  wooden  splint 
held  by  straps.     Adhesive  plaster  to  foot  and  ankle. 


371 


372 


FRACTURES    OF    THE   LEG 


rect  the  deformity  without  doing  a  tenotomy  of  the  tendo  Achilhs. 
A  posterior  wire  and  side  splints  with  the  foot  held  fixed,  with  a 
moderate  traction  and  pads  placed  at  the  seat  of  fracture,  may  be 
of  service. 


Fig.  534. — Short-Desault  splint  for 
the  application  of  traction  to  lower  leg 
fractures.  Fracture  at  X.  Extension 
strips  up  from  the  fracture  are  fastened 
at  the  top  of  the  splints.  Extension 
strips  down  from  the  fracture  are  fast- 
ened to  the  foot-piece.  Tightening  the 
screw  at  foot-piece  makes  traction  and 
countertraction. 


Fig.  535. — Plaster  traction  splint:  a.  Appli- 
cation of  adhesive-plaster  extension  strips  as 
in  figure  534  ;  b,  plaster  bandage  allowing  exit 
of  extension  straps.  Note  space  left  below  the 
sole  to  allow  for  effective  traction  and  buckles 
to  which  the  upper  extension  is  attached. 


A  plaster-of- Paris  splint  with  extension  and  counterextension, 
after  the  principle  of  the  Short-Desault  apparatus  and  according 
to  Lovett's  adaptation  (see  Figs.  534,  535),  will  hold  some  of  the 
more  difficult  cases. 

Method  of  Application  of  the  Traction  Plaster-of- Paris  vSplint. — 


TREATMENT 


373 


From  the  scat  of  fracture  running  upward  and  from  the  seat  of 
fracture  running  downward  are  applied  extension  adhesive  plasters, 
with  webbing  attachments,  as  seen  in  the  diagram  (see  Fig.  535). 
Below  the  foot,  the  size  of  the  sole  of  the  foot  and  two  inches  thick, 
is  held  a  very  firm  pad  of  sheet  wadding.  A  plaster  bandage  is 
applied  to  the  leg,  according  to  the  usual  methods,  from  the  toes  to 
above  the  knee.  A  buckle  looking  upward  is  incorporated  in  the 
plaster  bandage  upon  each  side  of  the  leg  a  little  above  the  level  of 
the  knee.  A  slit  is  left  upon  each  side  of  the  ankle  for  the  lower 
extension  webbings  to  come  through  (see  Fig.  535).  After  the 
plaster  has  hardened  the  sheet-wadding  foot-pad  is  removed.  The 
upper  extension  straps  are  pulled  snugly  over  the  upper  edge  of  the 


Fig.  536. — Cabot  posterior  wire  splint,  as  used  or  open  ractures  (lateral  view).  Note 
protective  padding  of  splint  beneath  wound,  X,  to  facilitate  dressings  without  the  removal  of 
the  leg  trom  the  splint. 


plaster  splint  and  fastened  to  the  buckles  on  each  side.  Then  the 
lower  straps  are  pulled  taut  over  the  foot-piece  of  the  plaster. 
Countertraction  and  traction  are  thus  maintained  upon  the  frag- 
ments of  the  fracture.  A  window  is  cut  in  the  plaster  to  observe 
the  position  of  the  bones.  This  apparatus  is  efficient  in  many  in- 
stances in  which  it  is  otherwise  difficult  to  maintain  reduction. 

Operative  interference  with  suture  of  the  fragments  of  bone  is 
the  most  effective  method  of  treatment  in  troublesome  cases.  It 
is  always  \vise  to  delay  operating  until  after  the  primary'  effects 
of  the  injurs-  have  ceased — that  is,  until  after  the  acute  swelling 
has  subsided  and  the  damaged  tissues  have  had  time  to  recover 
themselves.  A  delay  of  ten  days  is  time  gained.  During  these 
ten  davs  some  one  of  the  methods  alreadv  mentioned  mav  sue- 


374 


FRACTURES   OF   THE    LEG 


ceed  in  holding  the  fracture  satisfactorily  so  that  operation  is 
unnecessar}^ 

Treatment  of  Open  Fractures  of  the  Leg. — Treatment  rests  upon 
the  presumption  that  ever\^  open  fracture  is  infected.  The  object 
of  treatment  is  to  convert  the  open  infected  fracture  into  a  closed 


Fig.  537. — Cabot  wire  splint  in  open  fractures,  viewed  from  above.  Leg  in  position; 
wound  of  soft  parts  seen  ;  dressing  removed  ;  side  splints  and  straps  seen.  Upper  and  lower 
ragments  held  by  permanent  bandages  during  inspection  of  the  wound. 


noninfected  fracture.  It  is  important  that  the  first  dressing  of 
the  wound  should  be  a  clean  one.  If  it  is  a  temporary'  dressing, 
the  wound  should  be  douched  with  boiled  water,  covered  with  a 
clean  absorbent  dressing,  and  the  leg  be  placed  upon  a  pillow 
splint. 

The    Permanent   Dressing. — Every   open   fracture   of  the   leg 


TREATMENT  OF  OPEN  FRACTURES 


375 


should  be  anesthetized  for  careful  examination,  diagnosis,  and  the 
initial  dressing.  The  leg  should  be  washed  with  soap  and  water 
and  scrubbed  with  a  gauze  sponge  or  soft  nail-brush.  The  leg 
should  be  shaved  of  all  hair  in  the  vicinity  of  the  wound,  and 
should  then  be  washed  with  liquid  sodae  chlorinatse  (chlorinated 
soda),  one  part  to  twenty.  This  will  most  effectually  free  it  from 
all  grease  and  oily  dirt. 

The  Wound  of  the  Soft  Parts.— This  should  be  moderately  en- 
larged to  allow  easy  access  to  its  deeper  parts.     There  are,  no 


Fig.  538.— Fracture  of  both  bones  of  the  leg.    Ununited  fracture  of  tibia.    Fibula  united 
(Massachusetts  General  Hospital,  1190.     X-ray  tracing). 


doubt,  cases  of  fracture  of  the  bones  of  the  leg  open  from  within 
outward  in  which  the  wound  is  small,  evidently  made  by  the  bone, 
in  which  it  is  prudent  to  seal  the  wound  and  to  regard  the  likeli- 
hood of  infection  as  absent.  These  cases,  chosen  in  the  judgment 
of  a  wise  surgeon,  may  do  well,  but  they  may  not;  therefore,  the 
author  believes  it  is  safer  to  advise  that  all  wounds  of  open  frac- 
tiu-es  be  enlarged  for  thorough  cleansing.  The  blood-clot  and 
detritus  should  be  washed  out  by  irrigating  with  a  warm  solution 
of  corrosive  sublimate,  i :  5000.  Irrigation  should  be  supple- 
mented by  thorough  scrubbing  of  the  tissues  of  the  wound  by 


376  FRACTURES   OF   THE   LEG 

small  gauze  swabs  held  in  forceps.  These  swabs  should  be  small 
enough  to  be  carried  into  all  the  recesses  of  the  wound.  All  bleed- 
ing should  be  checked.  Loose  bits  of  muscle,  fat,  fascia,  and  bone 
should  be  removed.  Often  the  finger  will  detect  bits  of  bone 
when  the  forceps  will  not.  The  firmly  attached  fragments  of  bone 
are  to   be  left  undisturbed.      Regarding  the  treatment  of  the 


Fig.  539.— Open  fracture  of  both  bones  of  the  right  leg  in  the  lower  third,  six  months  after  the 
accident.     Note  the  deformity  and  enlargement  of  the  leg  near  the  ankle. 

slightly  fixed  fragments  of  bone,  the  surgeon  must  judge  in  each 
instance.  It  is  a  good  rule  when  in  doubt  about  the  viability  of  a 
fragment  of  bone  to  remove  it.  The  deep  fascia  may  need  division 
to  permit  of  a  view  of  the  depths  of  the  wound.  The  fractured 
bones  are  then  to  be  approximated  and  sutured,  if  practicable. 
The  corners  of  the  wound  mav  be  sutured.     It  is  wise  to  leave  the 


TRKATMUNT 


377 


wound  open  enough  to  receive  several  temporary  gauze  wicks  for  ^X^'lnt- 
drainage  during  the  first  few  days.  Counteropenings  may  be  '  ' 
needed  if  one  is  not  sure  of  the  aseptic  condition  of  the  wound. 
They  do  no  harm  and  may  prove  safety-valves  against  latent  in- 
fection. Before  leaving  the  wound  it  should  be  thoroughly 
douched  with  boiled  water.  An  aseptic  dressing  is  applied,  and 
the  leg  is  immobilized  by  the  posterior  wire  and  side  splints  (see 
Figs.  536,  537)  or  is  put  up  immediately  in  a  plaster-of- Paris  splint. 


Fig.  540. — Lateral  view  of  figure  539.     Note  discharging  sinuses. 


If  the  plaster-of- Paris  splint  is  used,  a  window  should  be  cut  in  it, 
through  which  the  wound  may  be  dressed. 

Care  of  a  Fracture  of  the  Leg  after  the  Permanent  Dressing  has 
been  Applied. — All  fractures  of  the  leg  will  be  placed,  sooner  or 
later,  in  the  fixed  plaster-of-Paris  splint.  One  week  after  the 
splint  is  applied  the  patient  may  be  up  and  about  with  crutches. 
At  first,  the  hanging  of  the  leg  down  may  be  attended  by  great  dis- 
comfort. There  may  be  a  sense  of  fullness  and  of  burning  in  the 
leg.  The  leg  mav  feel  as  if  it  would  burst.  The  toes  may  look 
blue  and  be  swollen.  As  the  patient  becomes  accustomed  to  these 
conditions,  which  are  in  themselves  harmless,  he  will  be  able  to 


378 


F'RACTURES   OF   THE   LEG 


ignore  them ;  they  will  grow  less  and  less  troublesome,  and  eventu- 
ally disappear.  At  the  end  of  four  or  five_  weeks  the  fracture 
should  be  found  firmly  united.  A  lighter  plaster  splint  may  be 
applied,  extending  only  to  the  knee-joint,  and  allowing  flexion  of 


Fig.  541 . — Ligaments  of  normal  ankle.    The 
mortise  for  the  astragalus  is  seen. 


Fig.  542. — Pott's  fracture  (diagram). 
Fracture  of  fibula,  tear  of  the  internal 
lateral  ligament.  Displacement  outward 
of  foot.  A  sliding  of  the  astragalus  upon 
the  articular  surface  of  the  tibia  without  a 
tilting  of  the  astragalus  upon  its  antero- 
posterior axis. 


the  knee.     This  thin  plaster  splint  should  be  split,  so  as  to  be  re- 
movable.    After  about  four  weeks  the  leg  should  then  receive  a 
daily  bath  and  massage,  with  active  and  passive  motion  to  the 
knee-joint.     At  about  the  eighth  week  the  protecting  splint  may 


TREATMKNT 


379 


be  reinovccl,  a  llaiiiu'l  l)an(la.i;v  fn>ni  ihv  tors  to  the  knee  substi- 
tuted, and  the  patient  l)e  allowed  to  loueli  the  foot  to  the  floor, 
bearing  a  little  weight.  As  soon  as  the  j^lasler  is  removed  and  the 
bandage  substituted,  a  shoe,  preferably  laced,  should  be  worn  on 
that  foot.  From  the  tenth  to  the  twelfth  week  after  the  injury 
the  patient  should  be  walking  with  a  cane.  According  to  present 
methods,  a  fractured  le.^-  woidd  recjuire  from  three  to  five  months 
of  treatment  before  restoration  to  normal  function  is  completed. 

The  after-care  of  a  ease  of  fraetnre  of  the  k\i;-  is  attended  with  no 
little  anxiety  on  the  part  of  the  surgeon.  The  general  health  of 
the  patient  is  a  matter  of  considerable  concern.  The  loss  of  exer- 
cise entailed  by  the  cramped  and  unnatural  position  causes  loss  of 


Fig-  543.— Case  :  Open  Pott's  fracture.     Wound  in  soft  parts  and  protruding  tibia  to  be  seen. 


appetite,  headache,  constipation,  dyspeptic  ills,  etc.  The  pain 
through  the  whole  limb,  due  undoubtedly  to  the  sprain  and 
wrenching  at  the  time  of  the  injury,  the  aching  at  night  at  the  seat 
of  the  fracture,  combine  to  render  the  patient  thoroughly  uncom- 
fortable, unhappy,  and  even  melancholy.  Pressure  spots  will 
appear  about  the  most  carefully  applied  bandage,  and  they  must 
receive  attention.  Itching  of  the  skin  inside  the  splints  is  some- 
times almost  unendurable.  To  every  patient  daily  general  and 
local  massage  and  bathing  will  be  found  to  be  of  unspeakable  com- 
fort. The  average  hospital  patient  is  far  less  sensitive  to  all  the 
pettv  annoyances  of  an  immovable  and  closely  fitting  dressing 
than  is  the  private  patient. 


38o 


FRACTURKS    OF   THE    LEG 


The  Prognosis. — In  children  and  young  people  the  minimum 
time  is  consumed  by  the  process  of  repair.  The  restoration  of 
the  leg  to  its  normal  function  is  more  rapid  than  in  the  cases  of 
adults,  and  there  are  fewer  complications.  In  adults  a  chronic 
arthritis  may  appear  in  the  neighboring  knee-  or  ankle-joints. 


Fig.  544.— Normal  leg  and  foot  at  a  right  angle.     Note  the  relative  position  of  heel  and  leg 


Fig.  545.— Pott's  fracture.  Posterior  displacement  of  the  foot  on  the  leg.  Note  the  short- 
ening of  the  foot  from  the  toe  to  the  front  of  the  ankle.  Compare  the  relative  position  of  the 
heel  and  leg  with  the  same  in  figure  544. 


Swelling  of  the  leg  and  ankle  may  persist  for  some  time.  Non- 
union of  the  bones  may  result,  and  necessitate  operative  measures 
(see  Fig.  538).  IJ^^^Jxa^XmS^M:^^^^  shortening  may  occur 
even  after  union  takes  place  if  the  unsupported  leg  isu^  To  o  soon 
and  too  much.     If  the  wound  of  an  open  fracture  heals  quickly, 


RESULTS    AFTER    TK1:aTMKNT 


381 


and  there  is  liulr  ciinninut  ion  <.l  hone,  repair  will  lake  place  as  in 
a  closed  fraelnre.  Otherwise,  an  open  fracture  will  unite  more 
slowly  than  a  closed  fracture.  Persistent  swelling  of  the  leg,  par- 
ticularly about  the  ankle,  is  associated  with  the  convalescence 
from  an  open  fracture.  Necrosis  of  bone  at  the  seat  of  fracture 
may  occur  in  cases  of  open  fracture  even  many  months  or  years 
after  the  original  injury.  Abscesses  and  sinuses  may  form,  neces- 
sitating operation  for  the  removal  of  the  necrosed  bone  (see  Figs. 
539^  540).  If  the  fracture  is  near  the  knee-  or  ankle-joints,  the 
prognosis  is  inore  uncertain  than  if  the  fracture  is  at  the. center  of 


^UsU 


Fig.  546.-Line  of  measurement  to  detect  backward  displacement  of  the  foot  on  the  leg. 


thejhaft,  A  comminuted  fracture  is  more  likely  to  be  longer 
in  uniting  and  to  give  rise  to  trouble  after  repair  than  is  a  single 
transverse  fracture. 

Results  after  Fracture  of  the  Leg.— Of  value  in  this  connection 
are  the  results  following  fracture  of  the  leg  in  thirty-five  cases 
treated  at  the  Massachusetts  General  Hospital,  and  examined 
one  and  a  half  to  ten  years  after  the  accident.  In  the  detailed 
report  of  these  cases  the  exact  lesion  and  its  seat  will  be  stated. 
In  thirteen  cases— in  ten  of  which  the  age  w^as  forty-two,  the  rest 
under  thirty— the  result  reported  was  that  the  injured  leg  was  "as 
good  as  the  other  leg."     In  twenty-two  cases  the  result  was  a  leg 


Fig-  547 •■ 


-Pott's  fracture  of  left  ankle.     Method  of  examining  ankle.     Lateral  mobility  shown. 
Note  the  grasp  of  the  foot  and  the  leg. 


Fig.  548. — Case  :  Fracture  of  the  internal  and  external  malleoli  and  displacement  of  the  foot 

inward  and  backward. 


382 


RESULTS  AFTER  TREATMENT 


383 


permanently  ini])aii-e-d  in  some  parlicular.  Some  cases  had  Hat- 
foot,  dcforniily  of  llie  leg,  limited  motion  at  the  knee-joint,  lame- 
ness, necrosis  of  bone,  pain  in  the  fracture  when  the  weather  was 
damp.  Other  cases  had  pain  in  the  leg  upon  standing,  stiffness  of 
the  ankle,  pain  upon  stepping  on  uneven  surfaces,  weakness  of  the 
leg,,  swelling  of  the  leg  and  foot,  cramps  at  night  in  the  calf  of  the 
leg.  or  some  combination  of  these  symptoms. 


Fig.  549.— Same  as  figure  54S.     Lateral  displacement  of  foot  inward  (see  X-ray  tracing, 

Fig.  550)  ■ 


Thrombosis  and  Embolism. — Thrombosis  of  the  veins  about  a 
fracture,  and  particularly  about  a  fracture  in  which  there  is  some 
laceration  of  the  soft  parts,  is  not  at  all  uncommon.  At  times, 
and  rather  more  frequently  than  is  generally  supposed,  emboli  are 
detached  from  these  thrombi  and  cause  almost  immediate  death, 
with  symptoms  of  pulmonar\-  embolism — namely,  a  sudden  cyano- 
sis and  great  difficulty  in  breathing  associated  with  intense  precor- 
dial distress. 


1 


i^'Wh 


384  FRACTURES    OF    THE    LEG 

Thrombosis  of  the  veins  of  the  leg  or  thigh  is  undoubtedly  one  of 
the  causes  of  the  great  edema  seen  after  fracture  of  these  parts. 

Rejractnre  of  the  Bones  of  the  Lower  Extremity. — It  is  not  an  un- 
common experience  to  find  that  a  patient  with  a  fracture  of  the 
thigh,  leg,  or  patella  refractures  the  partially  united  bone.  This 
refracture  is  due  to  either  muscular  violence  or  a  slight  fall.  There 
is  ordinarily  little  displacement  of  the  fragments.  The  callus  of 
the  original  injury  holds  the  bones  quite  securely.  The  leg  is 
usually  bent  at  the  seat  of  the  fracture.  Re^acture  is,_therefOTe^ 
practically  a  fracture  of  callus.  This  accident  has  even  occurred 
while  the  patient  is  wearing  a  protective  splint  of  plaster-of- Paris. 
Union  in  these  cases  is  much  more  rapid  than  after  the  original 
injury.  About  one-half  the  time  required  for  union  of  the  original 
fracture  is  necessary  for  union  of  the  refracture.  The  patient 
may,  therefore,  be  much  encouraged,  for  though  the  accident  of 
refracture  is  a  disheartening  one,  yet  he  will  not  be  obliged  to  look 
forward  to  a  long  confinement. 


POTT'S  FRACTURE 

^"^V  iO  Anatomy. — The  anatomical  relations  of  the  lower  ends  of  the 

ilbilO  fibula  and  tibia  and  the  astragalus  and  os  calcis  should  be  kept 
constantly  in  mind.  The  os  calcis  and  astragalus  are  held  firmly 
together,  forming  the  posterior  portion  of  the  foot.  The  astraga- 
lus rests  mortise-like  between  the  internal  and  external  malleoli 
(see  Fig.  541).  The  strength  of  the  inferior  tibiofibular  articula- 
tion depends  upon  the  strong  inferior  tibiofibular  ligaments,  par- 
ticularly upon  the  interosseous  ligament. 

By  Pott's  fracture  of  the  ankle  is  understood  the  injury  caused 
by  forcible  eversion  and  abduction  of  the  foot  upon  the  leg.  The 
lesions  which  may  be  present  in  this  fracture  are  a  rupture  of  the 
internal  lateral  ligament,  a  fracture  of  the  tip  of  the  internal 
malleolus,  a  separation  of  the  lower  tibiofibular  articulation,  an 
oblique  fracture  of  the  fibula  two  or  three  inches  above  the  tip  of 
the  external  malleolus,  a  fracture  of  the  outer  edge  of  the  lower  end 
of  the  tibia.  Ordinarily,  the  mechanism  of  the  fracture  is  some- 
what as  follows :  As  the  foot  is  abducted,  the  strain  is  felt  at  the 
internal  lateral  ligament  and  at  the  inferior  tibiofibular  interosse- 


I'oTT  S    I-KACTIKK 


385 


oiis  liij^aniciil,  and  these  give  way-  H  the  force  continues,  the  f'  -'  '^ 
fibula  breaks  (see  V\%.  542).  If  the  force  still  continues,  the  inter-  'j''*']/* 
nal  nuilkolus  is  pushed  th^)u,^]l  the  skin,  and  an  open  fracture  re- 
svilts  (see  h'ig.  54,1).  If  the  internal  lateral  ligament  holds  against 
this  lateral  force,  the  tip  of  the  internal  malleolus  may  be  pulled  off. 
Symptoms. —  The  ankle  presents  a  very  constant  appearance 
after  this  fracture.  A  traumatic  synovitis  exists.  Great  swelling 
appears,  at  first  chiefly  upon  the  inner  side  of  the  ankle.  The 
ankle-joint  becomes  distended  with  blood  and  serum.     All  the 


Internal  malleolus. /  / 


■sJ-,' ' 


Internal  malleoli. 


1       > 

Fig.  550. — Fracture  of  both  malleoli  (anteroposterior  view).     Inversion  of  foot  (X-ray  tracing). 


natural  hollows  about  the  joint  are  obliterated.  The  foot  is 
everted,  appearing  to  have  been  pushed  bodily  outward.  The 
internal  malleolus  is  undtdy  prominent.  Some  of  this  prominence 
is  masked  by  the  swelling.  The  bonv  connections  and  natural 
support  of  the  foot  having  been  removed,  the  foot  drops  back- 
ward, partly  because  of  the  pull  of  the  calf -muscles,  but  chiefly 
because  of  its  own  weight  (see  Figs.  544,  545).  The  deformity, 
therefore,  is  a  double  one,  a  lateral  sliding  of  the  foot  outward  and 
an  anteroposterior  dropping  of  the  foot  backward.  The  malleoli 
-5 


386 


FRACTURES    OF   THE    LEG 


are  spread  apart :  the  measured  distance  between  them  is  increased 
over  the  normal.  Palpation  close  above  the  anterior  articular 
edge  of  the  tibia  and  the  astragalus  reveals  tenderness  over  the 
ruptured  tibiofibula  ligament.  The  backward  displacement  is 
best  measured  by  the  length  of  the  line  from  the  front  of  the  ankle 
to  the  cleft  between  the  first  and  second  toes  (see  Fig.  546) .  This 
line  will  be  found  shortened  upon  the  injured  side.  There  is  ten- 
derness over  the  fracture  of  the  fibula.  If  the  internal  malleolus 
is  fractured,  the  sharp  ridge  at  the  broken  edge  can  be  distinctly 


Os  calcis.  — 
Astragalus. 


Cuboid. 


■  Tibia. 


Fibula. 

Scaphoid. 

'  Os  calcis. 


Fig.  551. — Fracture  of  the  tip  of  each  malleolus.     Dislocation  of  the  foot  backward.     Note  the 
prominence  in  front  of  the  ankle.     Same  case  as  figure  550  (X-ray  tracing). 


felt.  Grasping  the  posterior  part  of  the  foot  firmly  with  the  whole 
hand  while  the  other  hand  steadies  the  lower  leg  just  above  the 
ankle,  abnormal  lateral  mobility  of  the  foot  may  be  detected  (see 
Fig.  547).  The  foot  will  be  felt  to  move  inward  to  its  natural  posi- 
tion. The  moment  inward  pressure  is  removed  the  foot  will  be 
seen  and  felt  to  slump  outward  again. 

Figures  548-551  inclusive  illustrate  a  reversed  Pott's  deformity, 
the  foot  having  moved  inward  instead  of  outward  as  w  ell  as  having 
fallen  backward. 

Treatment. — The  indications  for  treatment  are  to  place  the  parts 


POTT  S    FRACTURE 


387 


in  their  normal  rt-lations,  and  to  maintain  them  so  nntil  repair  is 
completed,  guarding  against  both  the  lateral  and  the  posterior 
deformities.  If  for  any  reason,  such  as  the  presence  of  very  great 
swelling  of  the  ankle,  it  is  expedient  to  delay  reduction,  the  leg 
should  be  placed  temporarily  in  a  pillow  and  side  splints  (see  Figs. 
517,  51S,  519).  An  anesthetic  should  always  be  administered 
before  the  reduction  of  this  fracture.  The  reduction  is  thus  ren- 
dered painless  and,  through  relaxation  of  the  muscles,  is  made  far 
easier.  The  principles  of  the  old  Dupuytren  splint  are  the  ones  to 
be  applied  in  the  reduction  of  this  fracture  whatever  the  apparatus 
in  which  the  leg  is  permanently  placed.     These  consist  of  the 


Diaphysis  of  fibula. 


Epiphysis. 


Diaphysis  of  tibia. 

Epiphysis. 

Astragalus. 


oi/oi/D 


Fig.  552. — Normal  ankle-joint,  showing  epiphyses  (anteroposterior  view) 


making  of  lateral  outward  pressure  upon  the  internal  malleolus, 
lateral  inward  pressure  upon  the  foot,  and  a  forward  lift  upon  the 
posterior  part  of  the  foot  or  heel.  The  practitioner  may  very 
properly  use  the  Dupuytren  splint.  It  is  thought  to  be  uncom- 
fortable, but  it  is  not  if  properly  applied.  It  is  ver^-  efficient  in 
holding  the  fracture  reduced. 

The  Dupuyiren  Splint. — This  is  a  board  from  one-quarter  to 
one-half  of  an  inch  thick,  long  enough  to  extend  from  the  middle 
of  the  thigh  to  six  inches  below  the  sole  of  the  foot,  and  as  wide  as 
the  calf  of  the  leg  from  front  to  back  (see  Fig.  560).  At  its  lower 
or  foot  end  it  is  serrated  with  three  or  four  teeth,  as  seen  in  the 


Upper  end  of  lower  frag- 
ment of  fibula. 


'-  Tibia. 


Astragalus. / 


C?-" 


ternal  malleolus. 


F'g-   553-— Pott's   fracture    (anteroposterior  view).     Notice  sliding   of   astragalus   outward. 
Fracture  of  internal  malleolus.     Fracture  of  fibula.     Extreme  deformity  (X-ray  tracing). 


I  Lower  fragment  of 

fibula. 


1  Fibula. 

'  Tibia. 


\ 

Os  calcis. 
Fig.  554. — Pott's  fracture.    Same  as  figure  553  (lateral  view). 


pott's   FRACTTKIv 


389 


illustration.  It  is  padded  with  folded  sheets,  so  that  when  it  is  J  iiLJjw 
applied  to  the  inner  surface  of  the  limb,  the  padding  extends  to  just  ajTjho 
above  the  level  of  the  internal  malleolus,  the  serrated  end  of  the 


Fracture  of  fibula. 


Fracture  of  internal 
malleolus. 


Fig.  555. — Pott's  fracture.    Almost  no  displacement.    Compare  with  figure  553  (Massachusetts 
General  Hospital,  82S.     X-ray  tracing). 


-Unusual  space. 
"Internal  malleolus. 


Fig.  556. — Pott's  fracture.     Notice  sliding  of  astragalus  outward.     Fractures  of  internal  mal- 
leolus and  fibula  (Massachusetts  General  Hospital,  54S.     X-ray  tracing). 


splint  projecting  six  inches  below  the  sole  of  the  foot.  The  pad- 
ding, as  seen  in  the  illustration,  is  so  thick  at  the  lower  end  over  the 
internal  malleolus  that  sufficient  room  is  left  for  inversion  and 


o 


Astragalus 


—  Fracture  of  fibula. 


Fig.  557. — Pott's  fracture,  showing  fracture  of  the  fibula  and  but  slight  sliding  of  the  astra- 
galus, a  sufficient  distance,  however,  to  have  made  a  rupture  of  the  internal  lateral  ligament 
highly  probable  (X-ray  tracing). 


Fig.  558. — Splintering  of  the 
lower  end  of  fibula  (Massachu- 
setts General  Hospital,  1105. 
X-ray  tracing). 


Seat  of 

fracture. 


Fig.  559. — Fracture  of  the  internal  malleolusJ( Massa- 
chusetts General  Hospital,  1084.     X-ray  tracing). 


390 


POTT  S    FRACTURIC 


391 


rotation  of  the  foot  upon  its  anteroposterior  axis  without  its  im- 
pinging upon  the  splint  in  the  least.  The  splint  is  held  in  place  by 
straps  and  buckles :  one  is  placed  above  the  ankle,  one  above  the 
knee,  and  a  third  is  placed  at  the  upper  end  of  the  splint.  For  the 
proper  application  of  the  splint  an  assistant  is  needed.  The  splint 
is  applied  while  the  leg  rests  upon  the  bed.     An  assistant  steadies 


Fig.  560. — Pott's  fracture.     Diipuytreii's  splint.     Note  length  of  splint ;  position  of  straps  ; 
arrangement  of  padding  ;  space  between  foot  and  splint. 


the  splint  and  the  leg  so  that  they  both  project  clear  of  the  foot  of 
the  bed.  A  roller  bandage  is  then  applied  in  circular  turns  about 
the  ankle  and  splint  from  the  splint  toward  the  leg.  After  two 
circular  turns  are  made,  the  assistant  adducts  and  inverts  the  ankle 
and  foot,  and  this  position  is  held  by  the  third  turn  of  the  bandage, 
which  is  passed  around  the  forward  part  of  the  foot  and  over  one 


392 


FRACTURES    OF    THE    LEG 


of  the  serrations  of  the  splint  (see  Fig.  561).  In  order  to  hold 
this  firmly  a  turn  is  then  taken  around  the  ankle.  A  figure  of 
eight  is  then  applied  for  several  turns  about  the  foot  and  ankle, 
crossing  the  ankle  in  front  of  the  instep  at  each  turn.  Each  suc- 
ceeding turn  is  caught  by  the  succeeding  serration  of  the  splint. 


Fig.  561. — Pott's  fracture.  Dupuytren's  splint. 
Note  serrations  of  splint  and  turns  of  bandage 
adducting  foot. 


Fig.  562. — Cabot  posterior  wire 
splint  bent  at  the  ankle  for  a  Pott's 
fracture  of  the  right  leg.  To  be  used 
to  assist  in  maintaining  adduction  of 
the  foot. 


At  the  same  time  the  foot  is  lifted  forward  by  pressure  from  be- 
hind, and  this  forward  lift  is  maintained  by  circular  turns  of  the 
bandage.  The  whole  limb  is  placed  upon  pillows.  Thus,  the 
eversion  and  posterior  dropping  of  the  foot  are  corrected.  This 
splint  forms  a  good  temporary'  or  emergency  dressing  for  Pott's 


TREAT.MIvXT    oF    I'OTT"s    FKACTURK 


393 


fracture.      This  dressing  corrects  the  eversion,  but  there  is  great  ' 
danger  that  the  foot  may  slump  backward  unless  most  carefully  }^jzj\\i. 
watched.     This  failure  to  hold  the  posterior  displacement  cor-  ' 

rected  is  the  defect  of  the  Dupuytren  splint. 

The  Posterior  Wire  Sfy/int  with  Curved  Foot-piece  (see  Figs.  562, 
563,  564). — The  posterior  wire  splint  extending  to  the  middle  of 
the  thigh  is  another  apparatus  used  in  treating  Pott's  fracture. 


Fig.  563.— Pott's  fracture.    Cabot  posterior  wire  splint  and  side  splints.    Note  position  of 
lateral  pads  and  twisted  foot-piece.    Side  splints  are  shown  unpadded  (diagram). 

The  foot-piece  should  be  twisted  at  the  ankle,  so  as  to  hold  the  foot 
when  inverted  fsee  Fig.  562 j.  The  splint  is  covered  and  padded 
in  the  usual  way  (see  p.  365).  The  patient  is  anesthetized.  The 
leg  is  placed  upon  the  splint.  The  foot  is  strongly  inverted  bv 
great  lateral  pressure  put  upon  the  posterior  part  of  the  foot.  This 
inversion  of  the  foot  can  not  be  made  too  stronglv,  for  the  deform- 
ity can  not  be  overcorrected.  The  position  of  extreme  inversion 
is  not  a  painful  one  to  maintain.     Ordinarily,  the  lateral  pressure 


394 


FRACTURES    OF    THE    LEG 


applied  is  too  slight  entirety  to  correct  the  deformity.  The  foot  is 
held  to  the  inverted  foot-piece  by  straps  of  adhesive  plaster,  pads, 
and  side  splints  (see  Fig.  563).  A  pad  is  applied  to  the  sole  of  the 
foot,  andso  placed_as  to_niaintainthe  lQng^anteropostoior.JaSh 
of  the  foot. 


It  is  found  that  if  this  is  not  done,  there  is  consider- 
able flattening  of  this  arch  upon  recoven,\  The  forward  lift  upon 
the  foot  is  made  and  maintained  by  proper  padding  posteriorly  to 
the  lower  leg  and  just  above  the  heel  (see  Fig.  564).  The  lift  may 
be  reinforced  by  smoothly  applied  strips  of  adhesive  plaster  placed 
laterally  on  the  foot  and  carried  under  the  heel  and  up  and  over 
the  end  of  the  foot-piece.  These  adhesive-plaster  strips  serve  as  a 
sling  for  the  foot.  There  is  one  other  way  to  avoid  pressure  upon 
the  point  of  the  heel,  and  that  is  by  placing  beneath  the  heel  a  ring 


Fig.  564. — Pott's  fracture.  Cabot  posterior  wire  splint,  adapted  to  the  adducting  of  the 
foot.  See  figure  530  for  method  of  slinging  foot  and  preventing  its  backward  displacement 
(diagram). 


of  sheet  wadding  covered  with  a  tightly  wound  bandage  (see  Fig. 
530).  These  methods  of  protecting  the  heel  from  pressure  may  all 
be  used  at  one  time  to  advantage.  The  side  splints  are  applied 
with  great  care,  being  so  padded  as  to  maintain  the  outward 
pressm-e  upon  the  inner  surface  of  the  lower  end  of  the  tibia,  and 
the  inward  pressure  upon  the  outer  surface  of  the  foot.  Ver}' 
great  care  must  be  exercised  that  there  is  no  recurrence  of  the 
deformity.     Frequent  readjustments  are  necessary-. 

The  Lateral  and  Posterior  Plaster-of-Paris  Splints  (Stinison's 
Splint). — The  posterior  splint  (see  Fig.  565)  extends  from  the  toes 
along  the  sole  of  the  foot  around  the  back  of  the  heel  and  up  the 
back  of  the  leg  to  the  knee  or  to  the  middle  of  the  thigh.  The 
lateral  splint  (see  Fig.  566)  begins  at  the  external  malleolus,  passes 


TRKATMHNT    OF    I'UTTS    FKACTURK  395 

over  the  dorsum  of  the  foot  to  the  inner  side  under  the  sole,  and  up- 
ward alons  the  outer  side  of  the  leg  to  the  same  height  as  the  poste- 
rior splint.  Kach  of  Hk-sl-  splints  is  made  of  about  six  or  eight 
strips  of  washed  erinoline,  four  inches  wide  and  long  enough  to  ex- 
tend from  around  the  foot  to  the  bend  of  the  knee  or  middle  of  the 
thigh.  The  leg  is  protected  by  roller  bandages  of  sheet  wadding. 
Plaster  cream  is  rubbed  into  the  crinoline  strips  one  after  the  other 


Fig-  565.— Pott's  fracture.     Stimson's  splint.     Posterior  plaster  (represented  two  inches  too 
long  at  the  upper  end). 

until  all  the  strips  have  been  used.  The  posterior  splint  is  applied 
first,  and  held  snugly  by  a  gauze  bandage  to  the  leg  and  foot. 
Then  the  remaining  crinoline  strips  are  likewise  covered  wdth 
plaster  cream  and  applied  as  the  lateral  splint  (see  Fig.  567).  This 
is  also  held  snugly  by  a  gauze  bandage  to  the  leg  and  foot.  During 
the  application  of  the  splint  and  until  the  plaster-of- Paris  has  set, 
the  foot  should  be  held  in  a  corrected  position  by  an  assistant. 


396  FRACTURES    OF    THE    LEG 

These  two  plaster-of- Paris  splints  are  preferable  to  the  encircling 
plaster  splint,  the  ordinary  "plaster  leg,"  for  by  their  use  the  ankle 
can  be  inspected.  Less  judgment  is  requisite  in  its  application  to 
insure  the  correction  of  the  deformity  than  by  the  use  of  the  ordi- 
nary "plaster  splint."     As  the  swelling  subsides  and  the  plaster 


Fig.  566. — Pott's  fracture.     Stims  m's  splint  completed.     Lateral  plaster  and  posterior  plaster. 

becomes  loose,  if  the  splints  are  kept  tight  by  bandaging,  the  de- 
formity can  not  possibly  recur. 

Care  of  the  Fracture  after  the  Permanent  Dressing  is  Applied. — 
If  the  posterior  and  side  splints  are  used :  After  the  initial  swelling 
has  subsided — i.  e.,  after  the  first  week — the  leg  may  be  placed  in  a 
plaster-of- Paris  splint  (circular  bandage),  and  the  patient  allowed 


TKl'ATMIC.NT    oF    PoTT's    1"KACTI'RE 


397 


up  and  about  willi  crutclKS.  TIk-  i)lasler  should  be  split  after 
application  and  held  in  i)lace  by  straps  or  a  bandage.  If  the 
Stimsoii  splint  is  used,  the  patient  may  be  allowed  up  and  about 
with  crutches  at  the  end  of  the  first  week. 

Massage  may  be  applied  to  the  exposed  parts  of  the  leg  and  foot 
dailv.  At  the  third  week  all  dressings  should  be  removed,  and 
gentle  massage  applied  to  the  whole  leg  from  toes  to  groin,  especial 
attention  being  paid  to  the  region  of  the  ankle.  Massage  and  gentle 
passive  motion  in  an  anteroposterior  direction  only  should  be  ap- 
plied at  least  once  or  twice  daily  after  the  second  week.  All  lateral 
motion  is  to  be  avoided.     After  the  fifth  or  sixth  week  a  flannel 


Pig.  567.— Foil's  fracture.     Stimson's  splint  lenioved.     Lateral  and  posterior  plasters. 


bandage  will  be  all  the  support  needed,  although  comfort  may 
demand  a  thin,  stiff,  retentive  splint  at  times.  At  the  end  of  two 
months  some  weight  may  be  borne  upon  the  foot. 

Of  the  three  methods  of  dressing  a  Pott's  fracture  the  posterior 
and  lateral  plaster  splint  of  Stimson  is  by  far  the  simplest,  and  it  is 
efficient  in  ever>'  way.  Moreover,  it  allows  of  massage  being  insti- 
tuted early  with  the  least  disturbance  to  the  ankle.  The  posterior 
wire  spli-t  is  more  difficult  of  application,  and  needs  careful  watch- 
ing end  frequent  readjustment.  \\'ith  the  posterior  wire  splint  in 
use  the  foot  or  leg  is  easily  accessible  to  early  massage  by  simply 
loosening  the  side  splints. 


398  FRACTURES    OF    THE    LEG 

Prognosis  and  Results. — In  young  adults  there  should  be  no 
deformity  and  almost  no  permanent  disability.  In  adults  there 
will  be  some  stiffness  for  a  time.  If  the  lateral  deformity  has  not 
been  completely  corrected,  a  traumatic  pronation  of  the  foot  will 
result.  The  longitudinal  arch  of  the  foot  should  be  supported 
always  by  a  suitable  pad  under  the  instep  for  at  least  six  months 
following  this  fracture,  whether  there  is  deformity  or  not.  If 
there  is  deformity,  it  will  relieve  the  pain.  An  insole  of  leather 
with  a  pad  stitched  to  it  for  support  to  the  arch  of  the  foot  is  often 
of  great  service.  If  there  is  no  pain  or  deformity,  it  will  strengthen 
the  foot  until  walking  is  easy  again,  and  will  prevent  deformity 
appearing.  If  the  anteroposterior  deformity  has  not  been  cor- 
rected, pain  may  be  experienced  upon  using  the  foot.  The  foot  is 
shortened  and  dorsal  flexion  is  much  hindered,  so  that  the  gait  is 
decidedly  impaired.  The  patient  will  walk  with  a  more  or  less 
stiff  ankle.  In  those  cases  in  which  there  is  great  deformity  asso- 
ciated with  extensive  laceration  of  the  soft  parts,  the  foot  and  ankle 
may  for  many  weeks  subsequent  to  union  be  painful,  stiff,  and 
swollen.  Pain,  stiffness,  and  swelling  increase  with  the  age  of  the 
patient — i.  e.,  the  younger  the  patient,  the  less  discomfort  will 
there  be  following  this  fracture. 

The  Operative  Treatment  of  Old  Pott's  Fractures. — The  in- 
dications for  operation  will  be  persisting  lateral  or  backward  dis- 
placements. The  only  method  for  the  relief  of  these  deformities 
is  by  osteotomy  of  the  tibia  and  fibula.  The  results  following  this 
operation  are  satisfactory. 

Open  Pott's  Fracture  (see  Fig.  543). — The  ankle-joint  is  in- 
volved. Two  things  are  to  be  considered  in  deciding  upon  the 
treatment  of  the  injury — the  extent  of  the  laceration  of  the  soft 
parts  and  the  amount  of  injury  to  the  bones.  If  the  laceration  is 
so  great  that  the  foot  is  useless,  amputation  is  indicated.  Ampu- 
tation is  indicated  in  only  two  other  instances — old  age  and  sepsis. 
If  the  laceration  is  not  great,  and  any  existing  dislocation  can  be 
reduced,  it  should  be  reduced  without  excision,  proper  drainage 
being  provided,  both  anteriorly  and  posteriorly,  to  the  joint.  If 
the  laceration  is  not  great  and  reduction  of  the  deformity  is  im- 
possible, then  either  partial  or  complete  excision  should  be  done. 


OPEN    POTTS    FRACTURE  399 

If  there  is  great  injur)-  to  bone,  whether  the  dislocation  can  or  can 
not  be  reduced,  a  partial  or  complete  excision  should  be  done.  In 
every  open  Pott's  fracture,  no  matter  how  small  the  wound  of  the 
soft  parts,  in  order  to  insure  an  aseptic  wound  it  should  be  en- 
larged sufficiently  for  thorough  cleansing  with  antiseptic  solutions 
in  ever\'  part.  Extreme  conservatism  should  characterize  the 
treatment  of  recent  open  Pott's  fracture.  In  the  large  majority 
of  cases  treated  upon  the  conservative  or  expectant  plan  a  useful 
ankle-joint  and  foot  will  result.  The  older  the  adult  patient  is, 
the  more  radical  must  be  the  treatment. 


<^XXi,0 


CHAPTER  XV 

FRACTURES  OF  THE  BONES  OF  THE  FOOT 

Fracture  of  the  astragalus  is  caused  by  a  blow  on  the  sole  of  the 
foot,  as  in  a  fall  from  a  height  (see  Fig.  568).  Fracture  of  the  os 
calcis  is  often  present  in  the  same  foot  with  fracture  of  the  astraga- 
lus. The  ankle-joint  may  or  may  not  be  involved.  The  diagnosis 
is  difficult  without  the  use  of  the  Rontgen  ray.  Crepitus  may  be 
elicited.     Great  swelling  may  appear  in  the  region  of  the  fracture. 


Tibia. 


Line  of  fracture. 


Head  and  neck  n^ 

of  astragalus.  /    \ 

Cuneiform.     Scaphoid.    \/ 


'  External 

I"         '      malleolus. 

■  Body  of  astrag- 


-  Os  calcis. 


J Cuboid. 


Fig.  568. — Fracture  of  the  neck  of  the  astragalus  (X-ray  tracing). 


It  is  highly  probable  that  many  cases  of  sprained  ankle  have  been 
cases  of  fracture  of  the  astragalus.  If  there  is  no  displacement, 
treatment  will  consist  in  immobilizing  the  ankle-joint  with  the 
foot  held  at  a  right  angle  with  the  leg.  As  soon  as  the  swelling  has 
begun  to  subside,  massage  may  be  used  to  advantage  and  con- 
valescence be  thus  hastened.  The  most  satisfactory-  dressing  is  a 
plaster-of- Paris  splint  extending  from  the  toes  to  below  the  knee, 
applied  and  immediately  split  open,  so  as  to  form  a  removable 
splint.     This  may  be  taken  off  for  massage  and  passive  motion. 

40  D 


FRACTURK  OF  THK  OS  CALCIS 


401 


Recovery  takes  place  with  fair  movement  at  the  ankle-joint,  so 
that  after  from  two  months  and  a  half  to  three  months  the  patient 
can  walk  without  support.     After  this  time  complete  recover)-  is 


External  malleolus.  f 

^^        / 
Posterior  fragment  "^v 

of  OS  calcls.  /      -. 

Inferior  fragment  "^  / 

of  OS  calcis.   \  •       / 


Tibia. 


Anterior  fragment 
of  OS  calcis. 


Fig.  569. — Fracture  of  the  os  calcis  in  the  body  of  the  bone  (X-ray  tracing). 


Line  of  fracture. 

Fig.  570. — Fracture  of  the  os  calcis,  almost  transversely  across  the  junction  of  the  body  and 
neck  (X-ray  tracing). 


slow.     More  or  less  stiffness  and  pain  may  exist  for  four  or  six 
months  after  the  accident. 

Fracture  of  the  Os  Calcis. — The  os  calcis  is  fractured  by  a  fall  on 
the  sole  of  the  foot,  as  well  as  by  a  powerful  contraction  of  the 
gastrocnemius  muscle  and  strong  tension  upon  the  tendo  Achillis. 
26 


402 


FRACTURES  OF  THE  BONES  OF  THE  FOOT 


It  may  be  crushed,  fractured  transversely  or  longitudinally,  or  a 
piece  may  be  torn  off  from  its  posterior  portion  near  the  insertion 


Fig.  571.— Fracture  of  the  left  os  calcis  through  the  body  of  the  bone  (X-ray  tracing). 


Astragalus. 


Line  of  fracture. 


Fig.  572.— Fracture  of  the  os  calcis.     The  part  torn  off  is  that  to  which  is  attached  the  tendo 
Achillis.     Notice  displacement  (Massachusetts  General  Hospital,  1652.     X-ray  tracing). 


of  the  tendo  Achillis  (see  Figs.  569,  570  inclusive).  The  symp- 
toms of  fracture  will  be  the  usual  ones  of  crepitus,  swelling,  pain, 
abnormal  mobility.     The  heel  is  seen,  by  comparison  with  its  unin- 


TRlvATMUNT 


403 


jiirccl  follow,  to  be  cnlart,a^d.     This  fracture  is  sometimes  associ- 
ated with  fracture  of  the  astragalus  (see  Fig.  575).     The  treatment 


Body  of  astragalus. I 


Neck  of  astragalu.s.  >—A- 
/ 


■^ External  malleolus. 

\ 

-\ — ^  Os  calcis. 

I .  Os  calcis,  posterior 

I  fragment. 


-1 —  Os  calcis,  anterior 

/  fragment. 


Fig.  573. — Fracture  of  the  right  os  calcis.    Same  patient  as  figure  568. 


Upper  border  of  os 

calcis. 


Os  calcis.  . — / \ 


Pig-  574- — Fracture  of  the  os  calcis  without  great  displacement  (Massachusetts  General 
Hospital,  102.     X-ray  tracing). 


is  to  immobilize  the  foot  at  the  angle  that  will  best  hold  the  frag- 
ment approximately  in  apposition.  Complete  plantar  flexion  of 
the  foot  may  be  needed  to  bring  the  fragments  well  into  position. 


404         FRACTURES  OF  THE  BOXES  OF  THE  FOOT 

The  pull  upon  the  tendo  Achillis  is  in  this  position  remoA'ed  from 
the  posterior  fragment.  Massage  should  be  instituted  early — 
during  the  first  week.  The  removable  plaster-of- Paris  dressing  is 
the  best  form  of  splint.  After  three  weeks  the  splint  should  be 
removed,  and  a  close  fitting  flannel  bandage  applied,  with  small 
pads  under  the  malleoli  and  on  each  side  of  the  tendo  Achillis. 
The  pads,  if  applied  with  considerable  pressure,  will  assist  ver}^ 
materially  in  reducing  the  swelling  and  in  restoring  form  to  the 
ankle.  It  will  be  about  two  months  before  the  patient  should  bear 
much  weight  upon  the  foot.  After  three  to  four  months  walking 
w^ill  be  comparatively  easy.  It  is  often  the  case  after  fracture  of 
the  OS  calcis  and  also  after  fracture  of  the  astragalus  that  there  is 


Fig.  575. — Case:  Posterior  viewof  fracture  of  right  os  calcis  and  of  left  astragalus.     Deformity. 
Note  fullness  each  side  of  the  tendo  Achillis  (see  X-ray  tracings  568  and  573). 


considerable  disturbance  of  the  normal  mechanism  of  the  foot. 
A  traumatic  flat-foot  results  from  the  accident.  This  can  be 
greatly  relieved  by  the  introduction  into  the  shoe  of  a  leather  pad, 
to  raise  the  instep  and  take  the  strain  off  the  injured  part.  The 
patient  may  find  that  for  a  period  of  six  months  or  more  the  wear- 
ing of  this  pad  is  a  great  support  and  comfort.  The  hot-air  baking 
is  verv^  satisfactory-  for  the  relief  of  the  pain  and  stiffness  felt 
throughout  the  ankle  and  foot.  The  hot-air  treatment,  combined 
with  massage,  helps  to  hasten  convalescence.  This  treatment 
should  be  used  once  daily  until  the  pain  in  the  foot  has  disap- 
peared. 

Open  fracture  of  the  astragalus  and  os  calcis,  if  treated  anti- 


FRACTURE  OF  THK  METATARSUS 


405 


septically,  recovers  with  a  useful  ankle  and  foot  even  though  the 
ankle-joint  is  ankylosed.  The  mediotarsal  joint  becomes  more 
flexible  than  it  ordinarily  is.  The  loss  of  motion  at  the  ankle-joint 
is  compensated  for  by  the  mediotarsal  joint  motion,  and  the  indi- 
vidual may  walk  with  hardly  a  perceptible  limp.  Removal  by 
operation  of  the  fractured  bone  is  attended  by  good  functional 
results,  and  if  the  bone  is  much  comminuted  or  dislocated,  opera- 
tion is  indicated. 

Fracture  of  the  Metatarsal  Bones  (see  Fig.  576). — This  fracture 


F'g-  576. — Metatarsus  and  phalanges,  showing  epiphyses  at  fifteen  years  (Warren  Museum, 

specimen  537). 


\      Seat  of  fracture. 
s    /        "TT  ~ri  !■  Sesamoid  bones. 


Fig-  577- — Fracture  across  the  first  metatarsal  of  the  right  foot  (X-ray  tracing). 


is  caused  by  direct  violence.  There  is  evidence  to  show  that 
indirect  violence  may  cause  a  fracture  of  metatarsal  bones. 
The  first  and  fifth  bones  are  the  ones  most  often  broken  (see  Fig. 
577).  The  symptoms  are  swelling,  pain,  crepitus,  and  abnormal 
mobility.  The  weight  can  not  be  borne  upon  the  foot  without 
pain.  There  is  never  great  displacement.  In  order  to  avoid 
trouble  in  walking  after  union  has  occurred,  it  is  wise  to  make 
the  approximation  of  the  fragments  as  nearly  accurate  as 
possible.  A  closed  or  simple  fracture  is  ordinarily  imcom- 
plicated.     Union  takes   place  in   from   three  to  four  weeks.     It 


4o6 


FRACTURES  OF  THE  BONKS  OF  THE  FOOT 


will  be  at  least  from  two  to  four  months  before  the  foot  can  be  used 
without  thought  of  the  injury  received. 

If  the  fracture  is  open,  repair  will  be  slower  than  after  a  closed 
fracture.  If  the  wound  is  kept  clean  and  free  from  infection,  no 
complications  will  arise.  If,  on  the  other  hand,  the  wound  be- 
comes infected,  necrosis  of  bone,  abscess  formation,  burrowing  of 
pus,  and  great  swelling  of  the  foot  may  occur,  all  of  which  will 
greatly  delay  the  healing  process.  The  foot  should  be  immobilized 
by  a  lateral  molded  splint  of  plaster-of- Paris.  This  should  be 
placed  upon  either  the  outer  or  inner  side  of  the  ankle,  according 
as  the  outer  or  inner  metatarsals  are  broken.     The  splint  should 


Fig.  578.— Fracture  of  the  first  phalanx  of  the  little  toe  (Massachusetts  General  Hospital,  115. 

X-ray  tracing). 


extend  from  the  middle  of  the  calf  of  the  leg  to  the  tips  of  the  toes. 
It  is  held  in  position  by  a  roller  bandage  of  gauze. 

Fracture  of  the  Phalanges  of  the  Foot.— These  fractures  are 
rather  unusual,  except  from  a  crush  of  the  foot  (see  Fig.  578). 
They  are  sometimes  open.  The  same  general  rules  of  treatment 
applv  to  fractures  of  these  bones  as  to  fractures  of  the  phalanges 
of  the  hand.  A  simple  plantar  splint  of  splint  wood,  padding  of 
the  toes,  and  adhesive-plaster  straps  will  be  sufficient  to  hold  the 
fracture.  If  the  plantar  splint  covers  the  entire  sole  of  the  foot,  it 
will  prove  of  great  comfort.  It  is  sometimes  wise  to  immobilize 
the  ankle-joint  by  the  thin  plaster  side  splint,  particularly  if  there 
is  swelling  of  the  leg  and  ankle. 


CHAPTER  XVI 

ANATOMICAL  FACTS  REGARDING  THE  EPIPHYSES 

HiTiiHRTO  our  knowledge  of  injuries  to  the  epiphyses  has  been 
obtained  mainly  through  clinical  and  pathological  observation. 
This  knowledge  is  only  approximately  correct.     \\"ith  the  assist- 


Fig.  5S0. — Relation  of  the  capsule  of 
the  shoulder-joint  to  the  upper  epiphyses 
of  the  humerus  (diagram). 


Fig.  579. — Epiphyses  of  humerus  at 
eight  years  (Warren  Museum,  specimeti 
334). 


Fig.  581. — Relation  of  the  capsule  of 
the  knee-joint  to  the  patella,  femur,  and 
tibia  (diagram). 


ance  of  the  Rontgen  ray  a  ver\"  great  advance  is  being  made  in  the 
accuracy  of  our  knowledge  of  the  epiphyses.  Whereas  there  will, 
perhaps,  always  exist  differences  in  the  times  of  the  appearance  of 
the  ossification  centers  and  the  times  of  union  of  the  epiphyses,  the 

407 


408  ANATOMICAL    FACTS    REGARDING   THE    EPIPHYSES 

discrepancies  in  each  observer's  series  of  cases  will  grow  less  and 
less. 

The  importance  of  an  exact  knowledge  of  the  epiphyses  to  those 
having  to  do  with  injuries  in  the  neighborhood  of  joints  is  un- 
doubted. The  diagnosis,  prognosis,  and  treatment  of  joint  inju- 
ries and  injuries  in  the  immediate  vicinity  of  joints  is  far  more 
satisfactory  than  ever  before.  The  book  by  John  Poland  upon 
"Traumatic  Separation  of  the  Epiphyses,"  from  which  the  follow- 
ing data  are  largety  taken,  marks  an  era  in  this  branch  of  surgery. 
Only  those  facts  that  are  considered  especially  important  for 
practical  everyday  use  are  here  mentioned. 


THE  DATE  OF  THE  APPEARANCE  OF  OSSIFICATION  IN  THE 
CHIEF  EPIPHYSES  OF  THE  LONG  BONES 

(After  Poland) 
At  birth  f   Lower  end  of  femur. 

I  Upper  end  of  tibia. 
At  one  year j    Upper  end  of  femur. 

t-   Upper  end  of  humerus. 
At  one  and  one-half  years J    Lower  end  of  tibia. 

I  Lower  end  of  humerus. 
At  two  years i    Lower  end  of  radius. 

t-  Lower  end  of  fibula. 
At  three  years  j    Great  trochanter  of  femur. 

I  Great  tuberosity  of  humerus. 
At  four  years /  Upper  end  of  ulna. 

I  Upper  end  of  fibula. 

From  five  to  six  years j   ^pper  end  of  radius. 

A ,    •   ,  .                                                       '      (    Lower  end  of  ulna. 
At  eight  years J 

1   Lesser  trochanter  of  femur. 


After  a  most  exhaustive  study  of  pathological  and  clinical 
material,  both  of  his  own  and  that  of  other  observers,  Poland  con- 
cludes that  the  order  of  frequency  of  separation  of  the  epiphyses  is 
about  as  follows: 

1.  The  upper  epiphysis  of  the  humerus. 

2.  The  lower  epiphysis  of  the  femur. 

3.  The  lower  epiphysis  of  the  radius. 

4.  The  lower  epiphysis  of  the  humerus. 

5.  The  lower  epiphysis  of  the  tibia. 

6.  The  upper  epiphysis  of  the  tibia. 


THE    l.oWIvK    IvPIl'HYSIS    oK    TIIIv    I'lvMUR 


409 


The  upper  epiphysis  of  the  humerus  is  composed  of  three  sepa- 
rate centers  of  ossification:  That  for  the  head,  appearing  at  two 
years;  that  for  the  great  tuberosity,  appearing  at  three  years; 
that  for  the  lesser  tuberosity,  appearing  at  four  years.  These 
three  centers  coalesce  to  form  the  upper  epiphysis,  and  it  unites, 
at  from  tlie  twentieth  to  the  twenty-fourth  year,  to  the  diaphysis 
of  the  humerus  (see  iMg.  579).  (For  Separation  of  this  Epiphysis 
see  p.  132.) 


Fig.  582.— Relation  of  the  capsule  of  the  knee-joint  to  the  lower  epiphysis  of  the  femur  and 
the  upper  epiphysis  of  the  tibia  (diagram) . 


<flU 


Fig.  5S3.— Epiphyses  at  the  wrist  at  seventeen  years  :  a,  Ulna  :  b,  posterior  surface  of  the 
radius  ;  c,  anterior  surface  of  the  radius  (Warren  Museum,  specimen  447). 


Separation  of  the  upper  humeral  epiphysis  will  not  necessarilv. 
excepting  in  cases  of  ver\^  great  violence,  open  the  shoulder- joint, 
for  the  capsule  is  firmly  attached  to  the  epiphysis  and  the  synovial 
membrane  is  loosely  attached  to  the  diaphysis  (see  P'ig.  580).  In 
the  adult  the  epiphyseal  line  marks  the  upper  limit  of  the  surgical 
neck. 

The  lower  epiphysis  of  the  femur,  the  largest  epiphysis  in  the 
body,  appears  before  birth,  attains  a  good  size  by  two  years,  and 


4I.O 


ANATOMICAL    FACTS    REGARDING   THE    EPIPHYSES 


unites  to  the  diaphysis  at  from  the  twentieth  to  the  twenty-third 
vear.      (For  Separation  of  this  Epiphysis  see  p.  314.) 

The  adductor  tubercle  is  on  the  diaphysis  marking  the  level  of 
the  line  of  the  epiphysis  upon  the  inner  side  of  the  femur.  The 
tW'O  heads  of  the  gastrocnemius  muscle  are  attached  to  both  the 
epiphysis  and  the  diaphysis,  but  chiefly  to  the  diaphysis.  The 
plantaris  is  attached  to  the  diaphysis.  Both  of  these  muscles, 
in  a  separation  of  the  epiph^'sis,  are  stripped  from  the  shaft  with 
the  periosteum,  and  act  solely  on  the  detached  epiphysis,  causing 
it  to  rotate  upon  its  transverse  axis.     In  separations  without 


Fig.  584. — Relations  of  the  synovial 
membrane  of  the  wrist-joint  to  the  epiphy- 
ses of  the  radius  and  ulna.  Note  also  the 
inferior  radio-ulnar  joint  and  synovial 
membrane  (diagram). 


Fig.  585. — Diagram  of  the  epiphyses  at 
the  elbow,  about  the  fourteenth  year:  a. 
Shaft  of  humerus;  b,  capitellum;  c,  head 
of  radius;  d,  internal  condyle;  e,  tro- 
chlear; /,  external  epicondyle. 


much  displacement  the  knee-joint  is  not  opened.  The  quadriceps 
bursa  may  escape  injury  (see  Figs.  581,  582). 

The  lower  epiphysis  of  the  radius  appears  about  the  second 
year,  and  unites  to  the  shaft  at  from  the  nineteenth  to  the  twen- 
tieth year.      (For  Separation  of  this  Epiphysis  see  p.  235). 

The  synovial  membrane  of  the  wrist-joint  does  not  touch  the 
epiphyseal  line  of  the  radius  either  anteriorly  or  posteriorly.  It 
takes  its  origin  from  the  lower  articular  margin  of  the  epiphysis. 
The  synovial  membrane  of  the  inferior  radio-ulnar  articulation 
extends  above  the  epiphyseal  lines  of  both  the  radius  and  ulna. 


THE    LOWICR    I'I'IPHYSIS   Ol-    TlHv    IIUMKRUS 


411 


It  is  loosely  conneclcd  with  the  diaphysis  of  each  bone.  In  epi- 
physeal separations  laceration  of  the  synovial  pouch  is  possible, 
but  is  not  absolutely  inevitable  (see  V'v^^.  S^a,  r>^4)- 

The  lower  epiphysis  of  the  humerus  is  formed  from  three  sepa- 
rate centers  of  ossification — viz.,  the  capitellum,  which  appears  at 
three  years;  the  trochlea,  which  appears  at  eleven  years;  the 
external  epicondyle,   which  appears  at  thirteen  years   (see  Fig. 


Fig.  586.— Tibia  showing  epiphyses  (War- 
ren Museum,  specimen  417). 


Fig.   587.— Fibula,  showing  epiphyses 
(Warren  Museum  specimen). 


585).  These  three  centers  coalesce  at  about  the  fifteenth  year, 
to  form  the  lower  humeral  epiphysis.  The  epiphysis  unites  to  the 
diaphysis  at  about  the  seventeenth  year.  The  epiphysis  for  the 
internal  epicondyle  forms  no  part  of  the  lower  humeral  epiphysis. 
It  appears  at  about  the  fifth  year,  and  joins  the  diaphysis  at  from 
the  eighteenth  to  the  twentieth  year.  (For  Separation  of  this 
Epiphysis  see  p.  175.) 

The  svnovial  membrane  at  about  the  fifteenth  year  and  after- 


412 


ANATOMICAL    FACTS    REGARDING    THE    EPIPHYSES 


ward  overlaps  the  epiphyseal  line.  The  epiphyseal  line  is  a  little 
higher  on  the  outer  side  than  on  the  inner.  It  inclines  obliquely 
downward  and  inward.  The  epiphysis  is  thinner  internally  than 
externally. 

The  epiphysis  of  the  lower  end  of  the  tibia  appears  about  the 
second  year,  and  unites  to  the  diaphysis  about  the  eighteenth 
or  nineteenth  year.  Neither  anteriorly  nor  posteriorly  does  the 
synovial  membrane  come  in  contact  with  the  epiph3'Seal  line,  so 
that,  unless  great  violence  is  exercised  or  the  epiphysis  is  fractured, 
the  ankle-joint  is  imopened  in  separation  of  this  epiphysis  (see 
Figs.  586,  587). 


Fig.  5S8. — Right  scapula  from  above  and  behind: 
a.  Epiphysis  of  acromion;  b,  epiphysis  of  coracoid 
process;  c,  epiphysis  of  g-lenoid  cavity  (from  speci- 
mens in  Warren  Museum). 


Fig.  589. — Relation  of  the  cap- 
sule of  the  hip-joint  to  the  upper 
epiphysis  of  the  femur. 


The  epiphysis  of  the  upper  end  of  the  tibia  (see  Fig.  586)  ap- 
pears at  about  the  first  year,  and  unites  to  the  shaft  at  the  twen- 
tieth or  twenty -second  ^^ear.  The  synovial  membrane  is  quite  a 
little  distance  from  the  line  of  the  epiphysis.  The  epiphyseal 
line  runs  quite  close  to  the  superior  tibiofibular  articulation. 

The  acromion  process  of  the  scapula  (see  Fig.  5S8)  presents  an 
epiphysis  that  appears  at  from  the  fourteenth  to  the  sixteenth 
year,  and  unites  at  from  the  twenty-second  to  the  twenty-fifth 
year.  The  epiphysis  includes  the  oval  articular  facet  for  the 
clavicle.  The  coracohumeral  and  acromioclavicular  ligaments 
are  attached  to  it.  The  epiphysis  joins  the  acromion  behind  the 
acromioclavicular  joint. 


CHAPTKR  XVII 
GUNSHOT  FRACTURES  OF  BONE 

The  civil  surgeon  rarely  has  opportunity  to  study  the  effect 
upon  bone  of  bullet  wounds.  He  may  see  in  his  practice  a  few 
gunshot  fractures.  His  experience  is  necessarily  limited.  The 
facts  contained  in  this  brief  chapter  are  taken  from  the  experience 
of  such  militarv'  surgeons  as  Kocher,  Treves,  Nancrede,  Makins, 
Senn,  Borden,  La  Garde,  and  others  who  have  during  the  past 
few  years  studied  scientifically  this  important  class  of  w'ounds. 

In  the  construction  of  the  modern  military  rifle  several  impor- 
tant changes  have  been  made.  The  bore  of  the  rifle  has  been  re- 
duced. The  caliber  of  the  bullet  has  been  lessened.  The  velocity 
of  the  bullet  at  the  muzzle  has  been  increased.  The  trajectors'  is 
more  flat.  The  revolution  of  the  bullet  upon  its  long  axis  is  in- 
creased. 

As  a  general  result  of  these  various  changes  the  modern  military' 
rifle  has  a  great  range  and  great  accuracy.  The  effect  of  the 
modern  bullet  upon  bone  is  described  as  concisely  as  is  possible 
in  the  following  paragraphs. 

The  amount  of  the  damage  done  to  bone  is  dependent  upon 
several  factors :  The  greater  the  velocit}'  of  the  bullet  when  the 
bone  is  struck,  the  greater  will  be  the  destruction  of  the  bone. 
The  nmzzle  velocity  of  the  modern  bullet  is  ordinarily  about  two 
thousand  feet  a  second.  The  less  the  velocity,  the  less  will  be  the 
destructive  effects.  The  velocity  may  be  just  sufficient  to  break 
the  bone  and  not  to  carr\'  the  bullet  through  the  limb.  The 
severity  of  the  injurs-  therefore  decreases  in  proportion  to  the  dis- 
tance which  interA'enes  between  the  rifle  and  the  object  struck. 
The  trained  military-  surgeon  may  read  the  range  in  the  character 
of  the  damage  done.  The  more  pointed  bullet  secures  for  itself 
greater  penetration  and  perforation.  The  bullet  acts  like  a  steel 
wedge  driven  with  great  velocity  through  the  soft  and  hard  parts. 

413 


414 


GUNSHOT   FRACTURES    OF    BONK 


The  primary  collision  area  is  small.  The  only  indisputable  evi- 
dence of  a  low  velocity  is  the  lodgment  of  an  undeformed  bullet. 
The  resistance  offered  by  the  tissues  is  lessened  and  the  resulting 


Fig.  590.— Sections  of  bullets  to  show  relative  shape  and  thickness  ot  mantles  :  i,  Geudes  : 
regular  dome-shaped  tip  ;  mild  steel  mantle ;  thickness  at  tip,  0.8  mm. ;  at  sides  of  body,  0.3 
mm.;  2,  Lee- Met  ford  :  ogival  tip;  cupro-nickel  mantle;  thickness  at  tip,  0.8  mm. ;  gradual 
decrease  at  sides  to  0.4  mm. ;  3,  Mauser  :  pointed  dome  tip  ;  steel  mantle  plated  with  copper 
alloy;  thickness  at  tip,  0.8  mm. ;  gradual  decrease  at  sides  to  0.4  mm.;  4,  Krag-Jorgensen  : 
ogival  tip  as  in  Lee-Metford ;  steel  mantle  plated  with  cupro-nickel;  thickness  at  tip,  0.6 
mm.;  gradual  decrease  at  sides  to  0.4  mm.  Note  the  more  gradual  thinning  in  the  Lee- 
Metford  (from  Makins'  "Surgical  Experiences,"  etc.). 


Fig.  591. — Four  common  types  of  lateral  Mauser  ricochet  bullets  (from  Makins'  "  Surgical 
Experiences,"  etc.). 


wounds  are  neat.  Important  parts  are  seemingly  miraculously 
avoided  by  the  bullet.  The  revolution  of  the  bullet  on  its  long 
axis  facilitates  a  neat  wound  of  entrance  through  the  skin.     The 


GUNSHOT    FKACTl'RHS    OF    BONE 


4'5 


Mauser  bullet  revolves  on  its  own  axis  once  in  8}  I  inches,  or 
about  half  of  a  full  revolution  in  the  perforation  of  a  limb.  The 
amount  of  deslruction  sulTered  by  any  ])art  of  a  bone  depends 
primarily  upon  the  amount  of  resistance  which  it  opposes  to  a 
bullet.  There  is  more  resistance  offered  by  the  cortex  found  in 
the  shaft  than  by  the  spongy  tissue  of  the  ends  of  the  long  bones. 
When  the  hard  shaft  or  cortical  bone  is  hit,  the  force  of  the  bullet  is 
expended  in  breaking  this  dense  and  resistant  bone  into  minute 
pieces. 

The  explosive  effect  of  a  bullet  is  dependent  upon  the  velocity 
remaining  to  be  expended  upon  the  small  particles  of  bone  broken 
off  by  the  initial  impact.     The  carrying  of  these  particles  of  bone 


Fig.  592. — Five  types  of  fracture  :  a,  Primary  lines  of  stellate  fracture  ;  6,  development  of 
the  same  lines  by  a  bullet  traveling  at  a  low  degree  of  velocity;  the  two  left-hand  limbs  seen 
in  (a)  absent ;  in  their  places  is  seen  a  transverse  line  ;  c,  typical  complete  wedge  ;  d,  incom- 
plete wedge;  e,  oblique  single  line  (from  Makins'  "  Surgical  Experiences,"  etc.). 


forward  into  and  through  the  tissues  causes  the  laceration  and 
tearing  so  characteristic  of  the  so-called  explosive  effect  of  a 
bullet.  The  detached  bony  particles  become  really  secondar\- 
missiles. 

Kocher  has  classified  the  parts  of  the  long  bones  injured  as  the 
diaphysis,  the  epiphysis,  and  the  part  between  the  two,  the  meta- 
phvsis.  The  cortical  layer  of  the  metaphysis  is  thin  and  the 
spong}'  tissue  is  in  evidence.  Uncomplicated  injuries  of  these 
three  parts  of  the  bone  are  usually  quite  characteristic  (see  Figs. 
594,  595,  602).  The  flat  bones  show  a  clean  perforating  wound 
similar  to  that  seen  in  the  short  bones.  The  cancellous  or  spongA- 
tissue  of  bone  is  ordinarily  perforated  completely  and  the  wound  of 
the  bone  is  usually  pretty  clean-cut.     Clean-cut  perforations  wdth- 


4i6 


GUNSHOT   FRACTURES    OF    BONE 


out  fracture  are  the  rule  in  the  neighborhood  of  the  joints  and 
epiphyses.  Makins  noticed  in  South  Africa,  among  the  wounds  he 
studied,  "the  striking  contrast  of  clean  perforation  and  extreme 
comminution  in  different  cases " ;  "the  occasional  occurrence  of 
fracture  of  a  very  high  degree  of  longitudinal  obliquity";  "the 
rarity  of  any  that  could  be  termed  transverse  fractures";  "the 
general  tendency  of  longitudinal  fissuring,  when  it  occurred,  to 


Fig.  593. — Diagrammatic  view  of  a  type 
of  fracture  of  the  femur,  the  bullet  entering 
on  the  anterior  surface  of  tlie  bone  caus- 
ing extensive  longitudinal  fissuring  of  the 
shaft.  The  articular  ends  of  the  same  have 
not  been  involved  in  the  fracture  (after 
Kocher). 


Fig.  594. — Diagram  of  a  type  of  frac- 
ture. The  entrance  wound  clean-cut,  the 
exit  wound  lacerated  and  larger  than  the 
wound  of  entrance  (after  Kocher). 


stop  short  of  the  articular  extremities  of  the  bones."  If  explosive 
effects  are  but  slightly  marked  it  is  probably  because  the  velocity 
remaining  was  insufficient  to  impart  enough  motion  to  the  de- 
tached particles  to  convert  them  into  secondary  missiles.  The 
greater  the  distance  between  the  rifle  and  the  bone  struck,  the 
lower  will  be  the  velocity  of  the  bullet.  Consequent^  the  splin- 
ters of  bone  will  be  fewer,  longer,  and  more  adherent.    On  the  con- 


GUNSHOT    FRACTlKIvS    oF    IJONlv 


417 


trarv,  the  iK-arcr  the  1)()1K'  to  tlic  rilk-.  the   sijlintcrs  will   be   more 
numerous,  shorter,  uualtaehed,  and  puU  eriz.ed  with  bone  sand. 

A  small  skin  wound  may  eonceal  a  serious  injurs-  to  the  bone 
beneath.  The  llesh  wounds  of  entranee  inllieted  by  the  modern 
rifle  are  mostly  trivial.  The  missile  with  its  great  velocity,  in 
face  of  slight  resistance,  will  retain  nearly  all  its  energ\',  imparting 
little  or  none  to  the  tissues.  The  exit  wound  may  be  small  or  large, 
depending  upon  the  presence  or  absence  of  the  explosive  effect  and 


Fig.  595.— Diagram  of  a  bullet  wound  of  the  metaphysis  of  the  femur.  The  smaller  en- 
trance wound  contrasts  with  the  larger  e.xit  wound.  The  absence  of  Assuring  is  rather  char- 
acteristic of  bullet  wounds  in  this  region  of  the  ends  of  the  bones  (after  Kocher). 


also  Upon  the  deflection  of  the  bullet.  Deflection  of  the  bullet  at 
the  distance  at  which  many  wounds  are  received,  as  pointed  out  by 
Xancrede,  occurs  more  commonly  than  is  taught.  Between  the 
discharge  of  a  bullet  and  its  arrival  at  the  mark  many  things  may 
happen  to  it,  resulting  in  a  complicated  w^ound  of  the  soft  parts 
and  an  extensive  comminution  of  bone. 

The  turning  of  a  bullet  by  impact  with  an  obstacle  in  its  course 
is  spoken  of  as  ricochet.   The  bullet  which  ricochets  may  enter  the 
body  not  necessarily  end  on,  but  in  any  position  and  wobbling 
27 


4i8 


GUNSHOT   FRACTURES    OF    BONE 


about.  Under  these  circumstances  the  wound  of  entrance  is 
greatly  increased,  and,  the  velocity  being  impaired,  a  lodged 
bullet  often  results.  However,  if  great  velocity  remains,  a 
ricocheting  bullet  may  cause  very  great  damage.  A  ricochet 
bullet  is  dangerous  because  its  penetrative  power  is  diminished, 
it  is  liable  to  be  retained  in  the  tissue,  serious  damage  results  to 
the  bone  if  it  is  struck,  and  a  badly  lacerated  wound  may  result 
in  the  soft  parts. 

These  facts  are  perhaps  of  interest :  The  old  flint-lock  ball  was 
Y^Q  inch    in   diameter.     The   Minie   rifle    (Crimean)    ball   was  -^-^ 


Fig.  596. — Gutter  fracture  ot  second  degree,  perforating  the  skull  in  the  center  of  its 
course.  The  external  table  alone  carried  away  at  either  end  (from  Makins'  "  Surgical  Ex- 
periences," etc.).   ■ 


inch  in  diameter.  Martini  Henry  ball  was  -^^  inch  in  diameter. 
The  modern  small  bore  Lee-Metford  is  -^-q  inch  in  diameter.  The 
Mauser  is  slightly  smaller  than  the  latter.  The  latter  two  bullets 
have  the  new  cupro-nickel  case.  The  others  were  the  old  lead 
bullets.  The  Mauser'  bullet  is  1.2 1  inches  long,  weighs  172.8 
grains,  is  0.275  inch  in  diameter,  has  a  muzzle  velocity  of  238  feet 
per  second,  and  makes  i  turn  to  the  left  every  9  inches.  The 
English  Lee-Metford  is  1.25  inches  long,  weighs  215  grains,  is  0.303 
inch  in  diameter,  and  has  a  muzzle  velocity  of  2000  feet  per  second. 
As  Ta  Garde  has  justly  remarked,  the  employment  of  smokeless 


TRlCATMIvNT 


419 


powder,  a  flatter  trajectory  and  greater  penetration,  and  the 
change  to  the  smaller  jacketed  projectiles  will  increase  the  number 
of  the  wounded  in  war,  but  the  woiuuls,  as  a  whole,  will  be  less 
grave — more  humane.  Soldiers  will  be  more  often  restored  to  the 
State  useful  members  of  the  community,  instead  of  cripples  and 
pensioners.  In  point  of  economy  the  new  projectiles  confer  a 
great   advantage. 

Treatment. — The  principles  underlying  the  treatment  of  closed 
fractures  are  to  be  followed  in  the  case  of  gunshot  fractures. 
But  there  are  a  few  considerations  worthy  of  note.  Avoid 
exploration  of   a   fresh   gunshot  fracture  upon  the  field.     IvOcal 


Fig.  597. — Diagrammatic  transverse  section  of  complete  gutter  fracture:  A,  External 
table  destroyed,  large  fragment  of  internal  table  depressed  (low  velocity  or  dense  bone)  ; 
£,  pulverization  and  comminution  of  both  tables  at  the  center  of  the  track;  C,  depression  of 
iimer  table  (low  velocity)  (from  Makins'  "  Surgical  Experiences,"  etc.). 


examination  to  determine  the  number,  size,  and  position  of 
fragments  is  unwise.  The  modern  bullet  is  usually  aseptic, 
smooth,  and  not  heated.  There  is  no  urgency  for  its  removal. 
It  appears  (Borden)  that  neither  ricochet  passage  through  other 
objects  nor,  lowered  velocit}^  markedly  increases  the  proneness  of 
the  jacketed  missile  to  produce  infection.  The  lodgment  of  a 
bullet  does  not  necessitate  the  treatment  of  the  wound  as  if  it  were 
an  infected  one.  The  dictum  of  von  Nussbaum — "The  fate  of  the 
wounded  rests  in  the  hands  of  the  one  who  applies  the  first  dress- 
ing"— applies  nowhere  with  as  much  force  as  to  the  wounded  in 
battle.     The  first  field  dressing  is  of  the  greatest  importance. 


420 


GUNSHOT   FRACTURES    OF    BONE 


Consideration  of  gunshot  traumatism  of  the  shaft  of  long  bones, 
as  shown  by  the  Rontgen  ray  in  connection  with  the  ultimate  out- 
come of  the  cases,  points  indubitably  to  the  conclusion  that  infec- 
tion or  noninfection  of  the  wound  should  influence  treatment, 
rather  than  the  amount  or  extent  of  bone  damaged  (Borden). 

In  noninfected  wounds  extensive  comminution  is  not,  as  a  rule, 
an  indication  for  operative  interference  of  any  kind.     Occlusive 


Fig.  598. — Clean  gutter  fracture  of  the  ilium  (range  about  300  yards).  The  gutter  was 
clean-cut  and  admitted  the  forefinger.  The  inner  and  outer  tables  of  the  bone  were  in  part 
blown  out  of  a  large,  irregularly'  circular  exit  opening  about  1%  inches  above  the  crest  of  the 
ilium.  The  cancellous  tissue  was  probably  entirely  blown  out.  Plates  of  the  outer  and  inner 
tables  still  remained  connected  by  their  periosteum  to  that  deep  aspect  of  the  iliacus  and 
gluteus  medius  muscles.  The  peritoneal  cavity  was  not  opened.  The  patient  did  well. 
Compare  with  gutter  fracture  of  the  skull,  seen  in  figure  596  (from  Makins'  "Surgical  Ex- 
periences," etc.). 


dressings  and  immobilization  give  assurance  of  the  best  possible 
results.  Where  there  is  considerable  comminution  shortening  of 
the  limb  will  probably  occur  as  a  result  of  the  comminution  and 
the  displacement  of  the  bone  fragments.  But  excellent  functional 
use  of  the  limb  may  be  restored,  unless  the  lesion  of  the  soft  parts 
is  extensive  and  motion  is  restricted  by  the  formation  of  cicatricial 
connective  tissue  in  the  traumatic  spaces  (Borden). 


TKIvATMUXT  42  1 

Where  infection  exists  removal  of  the  cause  under  aseptic  or 
antiseptic  precautions  is  indicated.  In  such  cases  complete 
cleansing  of  the  wound  and  removal  of  all  loose  bone  fragments, 
followed  by  drainage  and  antiseptic  dressings  and  irrigation,  will 
usually  suffice,  and  excision  or  amputation  will  only  have  to  be 
resorted  to  in  extreme  cases  (Borden).  Amputation  for  extensive 
fracturing  of  the  long  bones  is  almost  unknown  (N'ancrede). 

As  to  the  disinfection  of  the  limb,  primary  cleansing,  mainly  by 
soap  and  water,  of  course  should  precede  the  exploration;  and 
when  the  latter  has  been  carried  out,  a  second  cleansing,  prefer- 
ably with  corrosive  sublimate,  is  imperative. 


Fig.  599. — Superficial  perforating  fracture,  illustrating  lifting  of  the  root  at  both  entry  and 
exit  openings  (from  Makins'  "Surgical  Experiences,"  etc.). 


Immobilization  is  a  more  difficult  problem.  Makins'  remarks  : 
A  question  of  constant  difficulty  is  that  of  frequency  of  dressing. 
In  a  stationar\^  or  base  hospital  this  is  not  difficult.  When  the 
patient  is,  however,  being  moved  from  the  field  to  the  stationary- 
hospital,  and  thence  to  the  base,  the  movements  during  transport 
disturb  the  fixity  of  the  dressing.  No  fractures  of  the  thigh  or 
leg,  and  few  of  the  arm,  can  be  transported  for  any  distance 
without  material  disadvantage. 

If  possible,  all  fractures  of  the  arm,  thigh,  or  leg  should  be  kept 
at  a  stationar}^  hospital  for  a  period  of  three  or  more  weeks. 

The  necessity  for  primary-  amputation  chiefly  depends  on  the 
nature  of  the  injury  to  the  soft  parts,  less  commonly  on  the  extent 


422  GUNSHOT   FRACTURES    OF    BONE 

of  the  injury  to  the  bones,  and  should  be  decided  on  exactly  the 
same  lines  as  in  civil  practice.  So-called  intermediate  amputa- 
tions are  always  to  be  avoided  if  possible.  The  results  have 
been  bad  and  the  operation  should  only  be  undertaken  in 
cases  of  severe  sepsis  where  little  can  be  hoped  from  it,  or  for 
secondary  hemorrhage.  When  the  operation  could  be  tided  over 
until  the  septic  process  had  settled  down  and  localized  itself,  sec- 
ondary amputation  gave  very  fair  results.  In  either  intermediate 
or  secondary  amputation  for  suppurating  fractures  it  was  neces- 
sary to  bear  in  mind  the  special  likelihood  of  an  extensive  osteo- 
myelitis (Makins). 

The  very  great  mortality  attending  gunshot  fracture  of  the 
femur  previous  to  the  introduction  of  the  small-bore  rifle  makes  it 
important   to    consider   this   fracture   in   some    detail.     I   quote 


Fig.  600.— Diagrammatic  longitudinal  section  of  fracture  shown  in  figure  599  (from  Makins' 
"Surgical  Experiences,"  etc.). 


Makins  as  having  had  the  best  recorded  clinical  experience  in 
these  cases. 

First  with  regard  to  the  primary  signs  and  symptoms.  A  very 
considerable  degree  of  general  or  constitutional  shock  usually 
accompanied  them,  and  this  was  perhaps  more  constant  than  in  the 
case  of  any  other  injury  in  the  body.  Tocal  shock  to  the  part  was 
also  a  prominent  feature.  Abnormal  mobility  was  very  free  in 
the  badly  comminuted  cases.  Crepitus  was  often  loose,  and  of  the 
"bag-of -bones"  variety.  The  result  of  local  shock  and  conse- 
quent flaccidity  of  the  muscles  was  to  reduce  the  development  of 
primary  shortening;  in  some  cases  of  severe  comminution  this  w^as 
practically  nil  during  the  first  day  or  two,  when,  with  return  of 
tone  in  the  muscles,  it  sometimes  became  very  considerable. 

The  long  and  difficult  transport  is  the  most  unsatisfactory  ele- 
ment to  contend  with  in  the  treatment  of  fractures  of  bone  in  the 
field.  There  are  advantages  in  having  a  field  hospital  behind  the 
firing  line.     Sir  Wm.  MacCormac  has  said  that  the  ideal  treatment 


TKICATMIvXT 


423 


of  a  gunshot  fracture  of  the  femur  would  be  to  erect  a  tent  over 
the  man  where  he  fell  and  not  to  transport  him  at  all. 

The  plaster-of- Paris  splint  {niller  bandage)  spica  to  both  thighs, 
with  a  long  outside  splint  from  axilla  to  below  the  foot,  is  the  most 
satisfactory  immobilization  apparatus  for  these  cases  of  compound 
thigh  fracture. 

The  operative  mortality  following  compound  or  open  fractures 
of  the  femur  during  the  Crimean  war  was  about  73  per  cent.     Dur- 


Fig.  601. — Perforation  of  lower 
third  of  tibia,  showing  lifting  and 
Assuring  of  the  compact  roof  of  the 
tunnel.  Compare  with  figure  599, 
of  a  fracture  of  the  cranial  vaults 
(from  Makins'  "  Surgical  Experi- 
ences," etc.). 


Fig.  602. — Oblique  perforation,  implicating  both 
epiphysis  and  diaphysis.  Large  fragment  detached 
at  exit  aperture.  Caused  by  a  bullet  traveling  at  a 
low  rate  of  velocity.  The  dotted  lines  indicate 
the  course  of  the  track  (from  Makins'  "Surgical 
Experiences,"  etc.). 


ing  the  American  w^ar  it  was  about  53  per  cent.  During  the 
Franco-German  war  it  was  65  per  cent,  among  the  Germans  and 
90  per  cent,  among  the  French.  The  conser^^ative  mortality — 
i.  e.,  in  the  unoperated  cases — was,  under  these  same  conditions : 
Crimean  war,  72  per  cent. ;  American  war,  49  per  cent. ;  Franco- 
German:  German,  28  per  cent.;  French,  9  per  cent.  In  the  re- 
cent war  with  Spain  in  Cuba,  although  the  results  are  not  all 
tabulated,  during  1898-99  the  general  mortality  in  operated  and 
unoperated  cases  together  was  but   10  per  cent,  in  this  serious 


424  GUNSHOT   FRACTURES    OF    BONE 

injury.  Modern  surgical  methods  used  upon  wounds  of  bone 
caused  by  modern  military  weapons  will  bring  the  mortality-rate 
ver}'  low  indeed.  All  those  interested  in  this  department  of 
surgerv  will  await  final  statistics  with  hopeful  expectation. 

Prognosis  in  Fractures  of  the  Femur. — From  Makins'  "  Surgi- 
cal Experiences  "  :  "As  regards  mortality,  fractures  in  the  upper 
third  of  the  bone  proved  one  of  the  most  formidable  injuries  which 
came  under  treatment.  Suppuration  was  common,  at  least  60 
per  cent,  of  the  wounds  becoming  infected.  This  depended  on 
several  reasons,  often  inseparable  from  the  injuries,  or,  from  their 
treatment  in  field  hospitals;  such  as  (i)  the  exit  wound  being 
situated  in  the  dangerous  region  of  the  thigh;  (2)  ineffective 
dressing  and  fixation;  (3)  the  impossibility  of  insuring  primary 
cleansing  and  removal  of  detached  fragments  of  bone;  (4)  the 
necessity  of  the  early  transport  of  patients  to  the  stationary  or 
base  hospitals,  often  for  great  distances;  (5)  the  comparativ^ely 
long  period  that  often  had  to  elapse  before  the  opportunity  of 
doing  the  first  efficient  dressing  arrived.  Fractures  in  the  middle 
and  lower  thirds  of  the  bone  were  more  easy  to  treat  successfully, 
but  these  also  added  to  the  list  both  of  amputation  and  fatalities. 
Punctured  fractures  of  the  lower  articular  extremity  were  usually 
of  little  importance,  as  they  progressed  without  exception,  as  far 
as  my  experience  went,  favorably." 


CHAPTER  X\'I  II 

THE  RONTGEN  RAY  AND  ITS  RELATION  TO 
FRACTURES 

BV  E.  A.  CODMAN,  M.D. 

On  Januar}'  23,  1896,  Rontgen  read  his  announcement  of  the 
discoven-  of  the  X-rays  before  the  Physico-medical  Society  at 
Wurzburg.  The  extraordinary-  news  fled  over  the  world  in  an 
incredibly  short  time.  AA'ithin  a  few  months  skiagraphs  of  the 
bones  of  the  hands  appeared  in  every  newspaper  that  could  afltord 
an  illustration,  and  the  reporters  indulged  their  imaginations  and 
dwelt  on  the  advantages  the  new  discover^'  would  bring  to  medi- 
cine and  surgerA'.  The  strangeness  of  the  subject  offered  an  un- 
usuallv  brilliant  field  for  the  imaginative  and  humorous,  and  in 
consequence  it  will  undoubtedly  be  years  before  the  public  is  dis- 
abused of  its  first  erroneous  impressions.  Perhaps  more  people 
err  now  on  the  side  of  incredulity  than  credulity,  and  are  inclined 
to  regard  the  wonders  they  heard  of  at  first  as  "newspaper  talk." 
Medical  men  are  particularly  subject  to  this  criticism,  and  there 
are  manv  who  seem  to  feel  a  disappointment  in  the  results.  It  is 
unfortunate  that  Rontgen 's  original  article  was  not  widely  pub- 
lished in  the  first  place,  for  it  is  a  model  of  scientific  accuracy,  and 
contains  not  a  single  statement  that  has  not  been  substantiated 
again  and  again.  To  those  men  who  understood  the  limitations 
of  the  X-ray  that  this  article  pointed  out,  the  results  have  not 
been  disappointing.  On  the  contrary',  the  improvements  in  appa- 
ratus and  technic  have  enlarged  the  scope  of  its  use  and  increased 
the  importance  of  the  information  it  gives  us.  The  X-ray  depart- 
ment has  become  a  necessity  in  ever}-  large  general  hospital. 

In  discussing  the  value  of  Rontgen's  discover}^  in  a  book  on  the 
treatment  of  fractures  it  has  seemed  wise  to  point  out  some  of  the 
mistakes  that  are  commonly  made  in  the  interpretation  of  skia- 
graphs.    To  those  who  have  done  practical  work  with  the  X-rays 

425 


42  6    the;  rontgen  ray  and  its  relation  to  fractures 

this  chapter  will  be  valueless;  but  those  who  have  not  may  find 
in  it  some  assistance  in  their  effort  to  learn  what  real  value  the 
new  science  is  to  this  branch  of  surgery. 

Among  other  misconceptions  the  Crooke's  tube  was  supposed 
to  emit  a  very  powerful  light.  It  is  not  a  powerful  light,  but 
merely  a  faint  one  of  such  quality  that  it  is  able  to  penetrate  sub- 
stances that  ordinary  light  does  not.  It  is  its  peculiar  quality,  not 
its  intensity,  that  enables  it  to  penetrate  opaque  objects.  It  is 
invisible  to  our  eyes,  but  has  the  quality  of  causing  chemical  action 
on  a  photographic  plate  or  of  affecting  crystals  of  certain  sub- 
stances so  as  to  make  them  emit  a  faint  light.  A  sort  of  sand- 
paper made  of  these  crystals,  finely  ground,  forms  a  fluorescent 
screen.  A  fluoroscope  is  made  by  inclosing  such  a  screen  in  a 
light  tight  box  with  an  eyepiece  to  allow  the  observer  to  see  the 
crystal  side  of  the  sand -paper.  When  this  instrument  is  brought 
near  a  Crooke's  tube  in  action,  the  cr\'stals  become  luminous  and 
any  substance  that  is  not  easily  penetrated  by  these  rays,  when 
placed  between  the  source  of  light  and  the  screen,  will  cut  off  the 
rays  and  cast  a  shadow  on  the  sand-paper  that  can  be  seen  on  the 
side  away  from  the  object.  This  shadow  will  be  more  or  less  deep, 
according  to  whether  the  substance  cuts  off  more  or  less  rays. 
Thus,  iron  casts  a  darker  shadow  than  wood;  bone,  a  darker 
shadow  than  flesh.  In  general  the  opacity  of  different  substances 
varies  directly  with  their  atomic  weights.  In  the  same  way  the 
substance  placed  between  the  source  of  light  and  a  photographic 
plate  will  cut  off  some  of  the  rays  from  the  plate.  Where  these 
are  cut  off,  chemical  action  does  not  occur ;  where  some  of  the  rays 
go  through,  it  occurs  slightly;  where  the  object  does  not  interfere 
at  all  and  the  ra5^s  strike  the  plate  directly,  the  action  is  greatest. 
When  the  plate  is  developed,  we  get  a  picture  of  the  shadow  of  the 
object  with  its  most  dense  parts  most  deeply  shaded. 

Many  people  confuse  an  X-ray  picture  with  a  photograph 
They  take  it  to  be  a  photograph  by  X-ray  light.  It  is  not  a  pho~ 
tograph,  but  a  shadow-picture,  a  compound  silhouette,  a  projec- 
tion of  the  parts  of  an  object.  A  photograph  of  the  hand  is  made 
by  the  light  reflected  from  the  hand  to  the  photographic  plate,  and 
shows  the  surface  of  the  skin.  A  skiagraph  of  the  hand  is  made 
by  the  light  that  has  passed  through  the  hand,  and  shows  a  chart  of 


MISTAKES    I.\    IXTKRI'KlvTATlON    OF    SKIAGKArilS  427 

the  dilTcrent  densities  of  tlK-  dilTerent  eonslitiients  of  the  hand,  as 
bone,  muscle,  fat,  and  skin.  As  the  other  parts  of  the  hand  are  of 
about  equal  density  and  this  density  is  much  less  than  that  of  bone, 
the  bones  appear  prominently  on  the  chart.  The  thickest  portions 
and  most  dense  portions  of  the  bone  appear  more  deeply  marked 
than  the  lighter  and  spong)^  portions.  As  evers-  little  gradation  of 
density  is  registered,  the  whole  forms  a  picture. 

As  far  as  we  know,  the  effects  of  the  X-rays  are  only  obtainable 
in  the  immediate  neighborhood  of  their  course;  that  is,  a  small 
point  on  the  platinum  reflector  in  the  Crooke's  tube.  From  this 
point  they  radiate  in  all  directions,  their  power  gradually  dimin- 
ishing until  at  a  distance  of  about  a  hundred  feet  or  a  little  more 
they  are  not  appreciable  by  any  means  now  at  our  command. 
Practically,  they  are  only  strong  enough  for  skiagraphic  pvu-poses 
within  a  few  feet  of  the  tube. 

Since  they  proceed  from  a  point,  and  are  not  approximately 
parallel  like  the  sun's  rays,  their  shadows  are  necessarily  distorted. 
We  are  all  familiar  with  the  distorted  shadows  thrown  on  the  wall 
by  a  candle.  The  same  distortion  takes  place  in  an  X-ray  pictiure 
in  a  lesser  degree.  vSince  the  rays  proceed  from  a  point,  all  parts 
of  an  object  can  not  stand  in  the  same  relation  to  that  point  and 
the  surface  of  a  plate  at  the  same  time.  The  least  distortion  will 
take  place  when  the  object  is  in  contact  with  the  plate,  and  as  far 
from  the  light  as  is  consistent  with  obtaining  sufficient  effect  to 
take  the  picture :  that  is,  to  have  the  ra^'S  penetrate  the  less  dense 
portions  of  the  object.  Let  the  distance  from  the  point  to  the 
plate  remain  the  same.     It  follows  that : 

(a)  Shadows  will  be  enlarged  in  proportion  to  the  distance  of 
the  object  from  the  plate,  toward  the  light. 

(b)  Shadows  are  distorted  of  any  object  or  part  of  an  object  not 
in  a  perpendicular  line  from  the  point  of  light  to  the  surface  of  the 
plate,  and  that  distortion  takes  place  in  a  line  drawn  from  the 
base  of  such  perpendicular  through  that  object  or  part  of  an  object. 

As  an  illustration  of  these  distortions,  we  have  represented  in 
figure  603  the  projection  of  a  cubical  block  of  wood  (a).  For  con- 
venience of  drawing,  the  shadow  (b)  is  represented  at  an  angle. 
The  outside  square  of  b  represents  the  upper  surface  of  the  block, 
while  the  inner  square  represents  the  lower.     The  density  of  the 


42  8   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

shadow  is  greatest  at  the  edges  of  the  lower  square,  for  they  repre- 
sent the  longest  paths  of  the  ra3's  through  the  block.  From  the 
consideration  of  figures  604,  605,  606,  and  607  the  reader  will  read- 
ily observe  that  any  change  in  the  tilt  of  the  plane  of  the  plate 
(Fig.  605,  a)  in  the  shape  or  densit}^  of  the  object,  or  in  the  distance 
of  the  point  of  light  (Fig.  606),  will  produce  a  definite  alteration  of 
the  shadow  or  picture.  It  is,  therefore,  necessary^  in  looking  at  a 
skiagraph  to  know  how  the  plane  of  the  plate  lay,  how  far  distant 


T'-tA-r 


Fig.  603. 


the  light  was,  and,  in  general,  what  the  shape  and  density  of  the 
different  parts  of  the  object  were. 

Just  as  it  is  true  that  the  shadow  of  any  object  increases  in  size 
as  it  is  moved  from  the  plate  toward  the  light,  so  also  it  is  true 
that  the  density  of  the  shadow  decreases  as  its  size  increases.  Each 
object  that  is  translucent  to  the  X-rays  seems  to  have  the  ability 
to  cut  off  a  certain  amount  of  X-ray  light.  In  other  words,  it 
contains  a  certain  amount  of  shadow-casting  material.     As  it  is 


THE  INTERPRETATION  OK  SKIAGRAPHS 


429 


moved  from  the  plate  toward  the  light  its  shadow  increases  in  size, 
but  diminishes  in  density,  since  only  a  certain  amount  of  light  can 
be  obstructed  by  that  object. 


k—?iaXe 


TLate 


Fig.  605. 


Putting  it  in  another  way,  we  see  that  the  object  .v  y  (Fig.  604) 
in  the  angle  ah  c  interferes  with  three  times  as  much  light  as  if  in 
the  position  oiade,  but  since  it  can  only  cut  off  a  certain  quantity 


430    the;  rontgen  ray  and  its  relation  to  fractures 

of  rays  in  either  position,  the  shadow  in  d  e  will  be  darker,  though 
smaller  than  h  c.  Of  course,  if  x  y  were  not  penetrated  at  all  by 
the  rays,  the  shadow  would  be  at  a  maximum  in  both  cases.  In 
ah  c  there  are  three  times  as  many  rays  to  go  through,  but  x  y  can 
only  subtract  a  certain  number.  It  can  subtract  that  number 
from  a  d  e  where  there  will  be  a  smaller  remainder  and  hence  a 
deeper  shadow.  This  is  an  especially  important  point  to  keep  in 
mind,  for  the  range  of  variation  of  density  of  different  bones  is 
very  small,  and  a  very  slight  change  in  position  in  relation  to  the 


Fig.  606. 


Fig.  607. 


plate  may  make  an  enormous  difference  in  the  resulting  picttu-e. 
For  example,  figure  608,  a  skiagraph  of  the  knee  taken  from  be- 
hind,— i.  e.,  with  the  plate  behind, — C  shows  little  or  no  sign  of  the 
patella.  While  with  the  plate  in  front  {B)  and  the  tube  behind, 
the  outline  of  the  patella  is  distinguishable  through  the  shadow  of 
the  femur.  This  is  the  more  decided  if  the  tube  is  brought  quite 
near  to  the  back  of  the  knee  {A),  for  then  the  size  of  the  shadow 
of  the  femur  is  increased  and  its  density  diminished,  while  that 
of  the  patella  remains  nearly  the  same  in  both  size  and  density. 
Another  point  that,  though  simple,  seems  to  cause  misunder- 


THK  IXTERPRKTATION  OF  SKIAGRAPHS 


431 


standinj^  is  illustrated  in  figure  607,  representing  the  shadow  of  a 
section  of  one  of  the  cylindrical  bones.  It  is  intended  to  show 
why  a  long  bone  appears  like  a  longitudinal  section  in  a  skiagraph. 
Though  the  whole  circumference  may  be  of  the  same  thickness,  the 
rays  that  pass  through  the  sides,  x-y,  meet  more  resistance  than 
those  through  the  center;  hence  the  medullary  cavity  appears  on 
the  plate. 

It  is  often  of  great  assistance  to  plot  out  on  paper  a  projection  of 
the  salient  points  of  the  subject,  as  in  figure  603,  at  the  same  time 
bearing  in  mind  that  variations  occur  in  densitv  as  well  as  in  size. 


TVaii 


PUt< 


Fig.  60S. 


We  should  like  to  go  into  the  question  of  the  deceptiveness  of  skia- 
graphs at  greater  length,  because  we  regard  it  as  of  the  utmost 
importance  that  ever}-  physician  who  uses  this  means  of  diagnosis 
should  fully  understand  the  wa}'  in  which  any  conclusion  should  be 
drawn  from  one  of  these  pictures.  Though  the  pictures  themselves 
are  inaccurate  as  pictures  of  the  object,  they  are  accurate  pictures  of 
the  shadows  of  the  different  parts  of  the  object,  and  the  reasoning  of 
conclusions  drawn  from  them  should  be  exact. 

In  answer  to  the  question  of  what  help  the  X-ray  has  been  in 
increasing  our  knowledge  of  the  pathology-  and  treatment  of  frac- 
tures, we  may  mention  first  the  general  points  and  then  the  par- 


432   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

ticular  fractures  in  which  we  find  it  to  be  of  benefit.  Although 
surgeons  have  alwavs  realized  very  nearly  accurately  the  position 
of  the  displaced  fragments  in  the  common  fractures,  there  can  be 
no  doubt  that  the  production  of  pictures  of  the  exact  condition 
in  individual  cases  gives  more  reliable  information  of  the  condition 
and  relation  of  the  broken  ends  than  can  possibly  be  obtained  by 
palpation.  A  more  definite  knowledge  of  the  pathology"  brings 
greater  exactness  of  treatment.  When  the  splints  are  applied,  it 
can  be  ascertained  whether  the  position  is  good  without  removing 
the  bandages.  Little  details  that  otherwise  would  escape  notice 
are  brought  out.  The  patient  is  spared  painful  manipulation  or 
etherization  and  the  bruising  and  laceration  of  the  tissues  from 
unnecessary  handling.  The  question  of  a  cutting  operation  to 
reduce  otherwise  intractable  fragments  may  be  decided  by  an 
exact  knowledge  of  the  positions  of  the  parts.  This  subject  of 
the  advisability  of  interference  by  making  a  simple  fracture 
compound  is  one  that  is  attracting  more  and  more  attention, 
and  will  lead  to  its  being  made  the  rule  in  cases  where  a  good 
result  can  not  be  expected  by  the  simple  method.  When 
asepsis  can  be  practised,  there  is  little  danger  of  making  an 
incision,  and  the  time  saved  in  cases  where  approximation  of  the 
fragments  is  prevented  by  loose  bits  of  bone  or  soft  parts  is  well 
worth  this  slight  risk. 

At  present  w^e  find  the  X-rays  of  more  assistance  in  the  study  of 
the  pathology  of  fractures  than  w-e  do  in  their  treatment.  For 
though  we  believe  that  in  each  individual  case  of  fracture  a  skia- 
graph is  of  decided  assistance,  yet  it  nmst  be  confessed  that  the 
cases  where  it  leads  us  to  modify  the  treatment  to  any  considera- 
ble extent  are  few  in  number.  An  exact  diagnosis  of  fracture 
without  skiagraphs  is  always  open  to  doubt,  while  with  a  careful 
X-ray  examination  there  is  seldom  a  doubt.  We  appreciate  the 
X-ray,  too,  when,  after  applying  our  splints,  even  if  plaster,  we 
assure  ourselves  of  the  correct  alinement  of  the  bones. 

As  a  means  of  demonstrating  to  students  the  pathology-  of  frac- 
tures, a  series  of  lantern-slides  of  skiagraphs  is  of  the  greatest 
assistance.  The  knowledge  that  the  pictures  are  of  actual  cases 
and  not  theoretic  diagrams  gives  a  practical  interest  that  is  akin 
to  clinical  instruction.     The  plates  when  shown  at  the  same  time 


ITS    PRACTICAL    VALUE  433 

as  the  case  at  a  hospital  clinic  also  serve  to  illustrate  the  pathology 
and  indications  for  treatment. 

A  not  unimportant  result  of  the  use  of  Rontgen's  discover)-  is 
the  exactness  it  offers  as  a  method  of  record  in  the  rarer  fractures. 
Heretofore  statistics  on  the  uncommon  forms  of  fracture  have 
always  been  open  to  the  doubt  of  mistaken  diagnoses,  and  we  have 
Vjeen  dependent  on  the  chance  of  securing  postmortem  specimens 
in  order  to  obtain  accuracy.  In  future  the  recorded  cases  of  this 
kind  can  be  illustrated  by  skiagraphs,  and  we  may  look  forward  to 
not  only  greater  accuracy,  but  to  a  much  greater  number  of  cases 
that  were  formerly  considered  rare.  Ever}-  large  hospital  will  be 
able  to  turn  to  its  records  and  say  definitely  in  what  percentage 
anv  given  fracture  occurred.  At  the  same  time,  each  individual 
case  has  the  benefit  of  a  definite  record,  and  the  result  can  be  com- 
pared with  the  extent  of  injur}'. 

The  reader  will  now  ask  in  what  forms  of  fractiu-e  can  we  say  the 
X-rav  is  of  great  assistance.  In  general,  those  bones  that  can  be 
brought  near  the  plate  or  that  are  not  overshadowed  by  other 
bones  give  the  most  satisfactory-  skiagraphs.  Therefore,  little  can 
be  expected  of  skiagraphs  of  the  bones  of  the  head  or  vertebrae, 
while  those  of  the  extremities  come  out  with  great  precision.  The 
pelvic  and  shoulder-bones  stand  midway  between  these,  but  with 
a  good  apparatus  and  care  in  the  choice  of  the  relative  positions  of 
the  plate,  tube,  and  the  particular  portion  of  the  bone  to  be  taken, 
we  may  expect  a  definite  picture.  Even  in  the  case  of  the  skull 
and  vertebrae  we  occasionally  find  a  skiagraph  of  advantage.  The 
entire  contour  of  the  lower  jaw  can  be  easily  investigated;  the 
nasal,  alveolar,  and  mastoid  processes  and  malar  bones  come  out 
sharply ;  the  cervical  vertebrae,  both  from  behind  and  from  the 
side,  can  be  brought  out  with  great  detail,  while  the  dorsal  and 
lumbar,  though  not  appearing  clearly,  sometimes  show  the  rough 
outlines  of  bodies  and  articular,  transverse,  and  spinous  processes. 
Any  particular  portion  of  any  particular  rib,  except  the  necks,  can 
be  taken  w^ith  great  accuracy;  since  the  plate  can  be  laid  almost 
directly  upon  it.  The  clavicle,  too,  comes  out  clearly.  The  ster- 
num is  too  much  overshadowed  by  the  dense  dorsal  vertebrae  to 
show  definite  outlines. 

Fractures  in  the  shoulder-joint  are  often  impossible  to  recognize 
28 


434   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

without  the  X-ray,  particularly  in  those  cases  where  the  swelling 
and  effusion  about  the  joint  prevent  manipulation.  Fractures  of 
the  tuberosities  of  the  humerus,  of  the  surgical  and  anatomical 
necks,  can  be  differentiated  with  great  certainty.  When  separa- 
tion and  dislocation  of  the  epiphysis  have  occurred,  we  may  decide 
the  question  of  operation ;  and  the  same  question  may  be  answered 
in  those  puzzling  cases  in  which  fracture  of  the  neck  has  occurred 
with  dislocation.  Separation  of  the  tuberosities  we  now  find  is  a 
much  more  common  accident  than  we  had  supposed.  Even  in 
breaks  of  the  shaft  of  the  humerus  and  the  other  long  bones  we 
gain  much  information.  The  extent,  direction,  and  plane  of  cleav- 
age, with  the  exact  amount  of  displacement,  are  guides  for  the 
application  of  padding  and  splints.  It  is  in  fractures  of  the  long 
bones  particularly  that  a  second  series  of  skiagraphs  with  the 
splints  in  position  is  of  value.  The  amount  of  shortening  is 
shown  more  accurately  than  by  measuring  the  landmarks,  for  the 
overlapping  can  be  distinctly  seen.  If  necessary,  the  approxima- 
tion of  the  fragments  can  be  aided  by  proper  pads. 

It  is  not  out  of  place  here  to  refer  again  to  the  question  of  distor- 
tion, for  in  these  cases  one  must  remember  that  not  only  may  the 
bones  be  magnified,  but  also  the  interspace  between  them.  Two 
or  more  pictures  must  be  taken,  for  a  view  from  the  side  will  often 
show  a  displacement  that  is  not  brought  out  in  the  shadow  from 
in  front  or  behind.  The  fluoroscope  is  particularly  useful  in  this 
sort  of  work,  for,  while  it  does  not  give  the  detail  that  can  be  seen 
in  a  plate,  it  is  clear  enough  to  assure  one  of  the  alinement  of  the 
parts  and  avoids  the  trouble  of  taking  and  developing  the  plates. 
In  general  work,  however,  we  place  less  reliance  on  the  fluoroscope 
than  on  the  skiagraph.  As  will  be  pointed  out  later,  the  use  of 
the  fluoroscope,  also,  is  not  without  danger  of  dermatitis. 

It  is  in  injuries  about  the  elbow-joint  that  we  must  be  more  than 
ever  upon  our  guard  to  avoid  false  conclusions  from  the  distortions 
that  we  have  endeavored  to  point  out.  It  will  be  most  useful  to 
any  practitioner  who  intends  to  do  X-ray  work  to  take  a  series  of 
skiagraphs  of  the  normal  elbow-joint  from  different  positions  and 
in  different  positions,  and  to  study  most  carefully  the  projections 
of  the  parts  in  each.  Such  a  series  of  injuries  occur  in  this  region 
that  the  diagnoses  are  most  difficult,  and  the  skiagraph  correctly 


ITS    PRACTICAL    VALUE  435 

interprclfd  is  of  the  grcatcsl  help.  Cases  lluil.  formerly  appeared 
in  hospital  records  as  "injury  to  elbow"  arc  now  divided  into 
"fractures  of  head  of  radius,"  "neck  of  radius,"  "separation  of 
coronoid  process,"  etc.  A  feature  which  is  now  thoroughly 
brought  out  is  the  common  occurrence  of  fracture  with  dislocation. 
Injuries  to  the  elbow  are  particularly  puzzling  in  children,  since 
the  ossification  of  the  epiphyses  is  found  in  different  stages,  and 
the  cartilaginous  portions  do  not  show  in  our  plates.  We  may 
expect  better  results  in  this  field  when,  by  stud}^  and  experience, 
we  learn  more  of  the  time  and  mode  of  formation  of  the  epiphyses. 

In  the  wrist  Rontgen's  discovers-  has  taught  us  much.  We  find 
in  the  fracture  of  the  lower  end  of  the  radius  a  variety  of  types. 
Breaking  of  the  styloid  of  the  ulna  is  found  to  exist  much  more 
often  than  was  supposed.  The  styloid  of  the  ulna  was  fractured  in 
80  per  cent,  of  140  cases  of  Colles'  fracture.  Fracture  of  the  scaph- 
oid is  also  not  uncommon  both  alone  and  in  conjunction  with 
Colles'  fracture.  Fractures  of  the  semilunar  and  os  magnum  are 
also  reported.  The  metacarpals  and  phalanges  offer  a  less  inter- 
esting field,  but  in  the  former,  when  impaction  into  the  distal  ex- 
tremity has  occmred  and  it  is  impossible  to  obtain  crepitus  or 
mobility,  a  skiagraph  shows  clearly  the  condition. 

Improvements  in  apparatus  and  technique  have  enabled  us  to 
get,  as  a  rule,  clear  pictures  of  the  upper  extremity  of  the  femur 
when  normal  or  recently  broken.  When  diseased  or  surrounded 
by  much  infiammator\^  thickening  or  calcareous  deposit,  the  out- 
lines are  blurred  and  unsatisfactory',  but  yet  throw  light  on  the 
diagnosis.  There  are  often  puzzling  cases  when  fracture,  disloca- 
tion, tuberculosis,  and  coxa  vara  all  have  to  be  considered,  and  in 
which  a  skiagraph  is  of  the  greatest  assistance.  Anv  portion  of 
the  shaft  of  the  femur  can  be  taken,  and,  since  portable  X-ray 
apparatus  have  come  into  use,  the  picture  may  be  obtained  with- 
out disturbing  the  patient  or  his  dressings.  Of  the  knee  we  get 
very  clear  plates.  Of  the  method  of  taking  the  patella  we  have 
already  spoken.  \A'e  can  compare  the  results  of  the  traction  treat- 
ment with  those  of  suture  and  wiring.  It  is  of  assistance  in  deter- 
mining whether  the  fragments  are  not  too  much  shattered  to  admit 
of  wiring. 

In  injuries  of  the  lower  leg  we  may  appl}-  what  has  already  been 


436   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

said  of  the  other  long  bones,  and  in  addition  mention  a  case  in 
which  a  fragment  from  the  external  malleolus  lodged  back  of  the 
astragalus  under  the  tendo  Achillis.  In  the  foot,  as  in  the  wrist, 
the  X-ray  has  taught  us  much.  Numerous  cases  of  breaks  in  the 
OS  calcis,  astragalus,  and  scaphoid  have  been  reported,  and, 
though  fractures  of  the  other  tarsal  bones  have  not  fallen  within 
our  experience,  their  occurrence  might  easily  be  recognized. 
Gocht  points  out  that  many  swollen  feet  of  uncertain  diagnosis 
prove  to  be  fractures  of  the  metatarsals.  He  also  reports  frac- 
tmre  of  one  of  the  sesamoid  bones  of  the  great  toe. 

It  is  commonly  said  that  the  X-ray  is  dangerous  to  the  patient 
and  burns  the  skin  and  destroys  the  hair.  This  is  true  as  a  possi- 
bility, but  nowadays  is  only  to  be  feared  in  connection  with  gross 
ignorance  and  carelessness.  It  is  a  fact  that  Crooke's  tube  in 
action  is  capable  of  causing  an  effect  on  the  tissues  similar  in  many 
respects  to  a  brun.  But  this  action  does  not  take  place  unless  the 
tissues  are  exposed  to  the  tube  for  a  considerable  period  of  time  and 
at  a  very  short  distance :  For  instance,  eight  inches  from  the  tube 
for  an  exposure  of  five  minutes  we  should  consider  perfectly  safe ; 
one  inch  from  the  tube  and  five  minutes,  dangerous.  Danger  in- 
creases as  we  prolong  the  time  of  exposure  or  diminish  the  dis- 
tance of  the  tube  from  the  skin.  Repeated  exposures  at  short 
intervals  are  approximately  equivalent  in  time  to  one  exposure 
equal  to  the  sum  of  all.  Probably  the  skins  of  different  people 
vary  in  susceptibility  to  this  influence,  but  we  doubt  if  injury  ever 
occurred  unless  the  tube  was  within  a  foot  of  the  patient. 

Danger  to  the  hands  of  the  operator  of  the  apparatus  is  quite 
another  matter,  for  repeated  exposure  may  produce  the  same  con- 
dition. The  most  severe  cases  occur  when,  in  the  use  of  the  fluoro- 
scope,  the  operator  puts  his  hand  near  the  tube,  either  to  hold  the 
patient's  limb  in  place  or  to  demonstrate  the  bones  of  his  hand  to 
an  audience.  Physicians  who  are  called  upon  to  use  the  fluoro- 
scope  often  should  wear  rubber  gloves  to  protect  the  hands,  or 
cover  the  tube  with  a  grounded  aluminium  screen.  Most  of  the 
recorded  cases  of  severe  injury  took  place  when  the  new  light  was 
first  used,  and  experience  had  not  pointed  out  these  cautions. 
To-day,  with  our  improved  apparatus,  the  penetration  and  defini- 
tion render  a  closer  approach  to  the  tube  than  twelve  inches  un- 


THE   LOCAL   liFKECT   OF   THE   RONTGEN    RAY  437 

necessan-.  The  cause  of  these  burns  has  been  a  subject  of  much 
discussion,  and  it  may  still  be  considered  an  open  question.  There 
are  many  who  believe  it  to  be  due  to  an  electrostatic  efTect,  while 
others,  among  whom  is  Professor  Elihu  Thomson,  affirm  that  the 
Rontgen  rays  themselves  are  responsible.  Professor  Thomson 
certainly  should  be  an  authority  on  this  point,  for  he  has  not  only 
the  advantages  of  his  electrical  knowledge,  but  also  of  experimen- 
tal experience.  The  following  is  a  quotation  from  a  personal  letter 
from  him  in  November,  1896,  describing  a  somewhat  heroic  ex- 
periment. 

' '  Hearing  of  the  effects  of  the  X-rays  on  the  tissues,  especially 
on  the  skin,  I  determined  to  find  out  what  foundation  the  state- 
ments had  by  exposing  a  single  finger  to  the  rays.  I  used  for  this 
the  little  finger  of  the  left  hand,  exposing  it  close  up  to  the  tube, 
about  one  and  one-quarter  inches  from  the  platinum  source  of  the 
rays,  for  one-half  an  hour.  For  about  nine  days  ver\'  little  effect 
was  noticed ;  then  the  finger  became  hypersensitive  to  the  touch, 
dark  red,  somewhat  swollen,  stiff ;  and  soon  after,  the  finger  began 
to  blister.  The  blister  started  at  the  maximum  point  of  action  of 
the  rays,  spread  in  all  directions  covering  the  area  exposed,  so  that 
now  the  epidermis  is  nearly  detached  from  the  skin ;  underneath 
and  between  the  two  there  is  a  formation  of  pirrulent  matter  that 
escapes  through  a  crack  in  the  blister.  It  will  be  three  weeks  to- 
day since  the  exposure  was  made,  and  the  healing  process  seems  to 
be  as  slow^  as  the  original  coming  on  of  the  trouble." 

Foiu"  days  later:  "The  whole  epidermis  is  off  the  back  of  the 
finger  and  off  the  sides  of  it  also,  while  the  tissue  even  iinder  the 
nail  is  whitened  and  probably  dead,  ready  to  be  cast  oft'.  The 
back  of  the  finger  for  a  considerable  extent,  where  it  received  the 
strongest  radiation,  is  raw  and  will  not  recover  its  epidermis,  ap- 
parently, except  from  the  sides  of  the  wound." 

Xot  entirely  satisfied  with  this  experiment,  Professor  Thomson 
shortly  afterward  repeated  it  on  another  finger,  which  he  covered 
with  some  aluminium  foil  in  such  a  way  as  to  convince  him  that 
the  tissue,  while  still  exposed  to  the  X-ray,  was  shielded  from  the 
brush  discharge.  As  he  obtained  the  same  result,  he  concluded  in 
favor  of  the  Rontgen  ray  itself.  In  a  recent  article  on  the  subject 
he  shows  that  this  effect  is  due  to  those  of  the  rays  that  are  less 


438   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

readily  transmitted  by  the  tissues  and  are  less  valuable  for  skia- 
graphic  purposes. 

This  quotation  is  made  not  only  from  its  value  as  an  experiment, 
but  also  because  it  is  so  clear  a  description  of  this  form  of  dermati- 
tis. The  long  period  before  the  effects  become  evident  is  quite 
characteristic,  although  in  many  cases  they  have  appeared  sooner. 
It  seems  probable  that  the  direct  effect  is  on  the  vasomotor  or 
trophic  nerve  supply,  which  eventually  affects  the  nutrition  of  the 
part. 

This  chapter  has  been  mainly  devoted  to  warnings  of  the  dan- 
gers of  the  Rontgen  ray,  and  may  in  a  measure  discourage  practi- 
tioners from  its  use.  It  should  be  stated,  however,  that  when  the 
limits  of  error  are  kept  clearly  in  mind,  the  actual  value  of  the  dis- 
covery to  surgical  science  is  very  great.  When  there  is  doubt  of 
the  diagnosis  of  a  fracture,  no  physician  has  done  his  full  duty  by 
his  patient  if  he  can  command  skiagraphic  examination  and  has 
not  used  it.  This  is  particularly  true  in  medicolegal  cases  where 
there  is  a  question  of  liability. 


Conclusions  Expressing  the  Views  oe  the  American  Sur- 
gical Association  upon  the  Medicolegal  Relations  of 
X-rays;  Adopted  in  May,  1900. 

1.  The  routine  employment  of  the  X-ray  in  cases  of  fracture  is 
not  at  present  (1900)  of  sufficient  definite  advantage  to  justify  the 
teaching  that  it  should  be  used  in  every  case.  If  the  surgeon  is  in 
doubt  as  to  his  diagnosis,  he  should  make  use  of  this  as  of  every 
other  available  means  to  add  to  his  knowledge  of  the  case,  but 
even  then  he  should  not  forget  the  grave  possibilities  of  misinter- 
pretation. There  is  evidence  that  in  competent  hands  plates  may 
be  made  that  will  fail  to  reveal  the  presence  of  existing  fractures  or 
will  appear  to  show  a  fracture  that  does  not  exist. 

2.  In  the  regions  of  the  base  of  the  skull,  the  spine,  the  pelvis,  and 
the  hips,  the  X-ray  results  have  not  as  yet  been  thoroughly  satis- 
factory, although  good  skiagraphs  have  been  made  of  lesions  in  the 
last  three  localities.  On  account  of  the  rarity  of  such  skiagraphs 
of  these  parts,  special  caution  should  be  observed,  when  they  are 


MEDICOLKGAL    RKLATIONS    OF    X-KAYS  439 

afTected,  in  basing  upon  X-ray  testimony  any  important  diagnosis 
or  line  of  treatment. 

3.  As  to  questions  of  deformity,  skiagraphs  alone,  without  ex- 
pert surgical  interpretation,  arc  generally  useless  and  frequently 
misleading.  The  appearance  of  deformity  may  be  produced  in  any 
normal  bone,  and  existing  deformity  may  be  grossly  exaggerated. 

4.  It  is  not  possible  to  distinguish  after  recent  fractures  between 
cases  in  which  perfectly  satisfactory'  callus  has  formed  and  cases 
which  will  go  on  to  nonunion.  Neither  can  fibrous  union  be  dis- 
tinguished from  union  by  callus  in  which  lime-salts  have  not  yet 
been  deposited.  There  is  abundant  evidence  to  show  that  the  use 
of  the  X-ray  in  these  cases  should  be  regarded  as  merely  the  ad- 
junct to  other  surgical  methods,  and  that  its  testimony  is  espe- 
cially fallible. 

5.  The  evidence  as  to  X-ray  burns  seems  to  show  that  in  the  ma- 
jority of  cases  they  are  easily  and  certainly  preventable.  The 
essential  cause  is  still  a  matter  of  dispute.  It  seems  not  unlikely, 
when  the  strange  susceptibilities  due  to  idiosyncrasy  are  remem- 
bered, that  in  a  small  number  of  cases  it  may  make  a  given  indi- 
vidual especially  liable  to  this  form  of  injury. 

6.  In  the  recognition  of  foreign  bodies  the  skiagraph  is  of  the 
very  greatest  value;  in  their  localization  it  has  occasionally  failed. 
The  mistakes  recorded  in  the  former  case  should  easily  have  been 
avoided;  in  the  latter,  they  are  becoming  less  and  less  frequent, 
and  by  the  employment  of  accurate  mathematical  methods  can 
probably  in  time  be  eliminated.  In  the  mean  while,  however,  the 
surgeon  who  bases  an  important  operation  on  the  localization  of  a 
foreign  body  buried  in  the  tissues  should  remember  the  possibility 
of  error  that  still  exists. 

7.  It  has  not  seemed  w^orth  while  to  attempt  a  review  of  the 
situation  from  the  strictly  legal  standpoint.  It  would  var}^  in 
different  States  and  with  different  judges  to  interpret  the  law. 
The  evidence  shows,  however,  that  in  many  places  and  under 
many  differing  circumstances  the  skiagraph  will  undoubtedly  be 
a  factor  in  medicolegal  cases. 

8.  The  technicalities  of  its  production,  the  manipulation  of  the 
apparatus,  etc.,  are  already  in  the  hands  of  specialists,  and  with 
that  subject  also  it  has  not  seemed  worth  while  to  deal.     But  it  is 


440   THE  RONTGEN  RAY  AND  ITS  RELATION  TO  FRACTURES 

earnestly  recommended  that  the  surgeon  should  so  familiarize 
himself  with  the  appearance  of  skiagraphs,  with  their  distortions, 
with  the  relative  values  of  their  shadows  and  outlines,  as  to  be  him- 
self the  judge  of  their  teachings,  and  not  to  depend  upon  the  inter- 
pretation of  others,  who  may  lack  the  wide  experience  with  surgi- 
cal injury  and  disease  necessary  for  the  correct  reading  of  these 
pictures. 


CHAPTER   XIX 
THE  EMPLOYMENT  OF  PLASTER-OF-PARIS 

Many  fractures  of  the  upper  and  lower  extremities  may,  at  some 
period,  ver^-  properly  be  treated  by  the  plaster-of-Paris  splint. 

The  plaster-of-Paris  should  be  of  the  best  quality  and  dry. 
Crinoline  is  used  for  bandages.  Commercially  it  is  called  Arrow- 
wanna  Crinoline  Lining.  It  is  a  lining  material  that  is  coarser 
meshed  than  the  cheese-cloth  used  for  gauze  bandages,  and  is  also 
stififer  than  cheese-cloth.  It  should  be  cut  into  four -yard  lengths, 
folded,  and  stitched  together.  Crinoline  contains  considerable 
sizing  or  glue.  This  is  detrimental  to  its  use  as  a  plaster  bandage. 
It  should,  therefore,  be  washed  of  the  sizing  in  lukewarm  water, 
thoroughly  rinsed,  and  rough  dried.  The  stitching  holds  the 
material  firmly  together  dtiring  the  washing.  It  should  then  be 
cut  into  strips  the  widths  of  the  desired  bandages.  Three  widths 
are  ordinarily  useful — namely,  widths  of  two  inches,  three  inches, 
and  five  and  one-half  inches.  These  fotur-yard  strips  are  made 
into  roller  bandages.  A  fine-meshed  gauze  bandage  is  being  used 
quite  commonly  in  place  of  crinoline. 

Rolling  the  Plaster. — It  is  a  simple  matter  to  make  one's  own 
plaster  roller  bandages.  It  is  possible  to  purchase  plaster  band- 
ages in  sealed  packages.  These  are  ordinarily  made  with  un- 
washed crinoline  and  are  less  desirable.  A  shallow  box  or  tray  is 
needed  to  hold  the  plaster.  Two  persons  can  roll  the  bandage 
with  facility.  "A"  manages  the  roll  of  crinoline,  straightens  it  as 
it  unwinds,  spreads  the  plaster  with  a  light  piece  of  board,  the  size 
of  the  hand,  while  "B"  draws  the  crinoline  across  the  tray  from 
imder  the  board  held  by  "A,"  and  rolls  up  the  bandage  loosely 
and  evenly.  "A"  w4th  the  board  held  still  and  plaster  heaped 
upon  the  bandage  behind  it,  regulates,  by  more  or  less  presstue 
upon  the  bandage,  the  amount  of  plaster  distributed  over  the 
crinoline.     It  requires  but  ten  or  fifteen  minutes  to  make  enough 

441 


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rt 

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442 


443 


444 


THK    EMPLOYMENT   OF    PLASTER-OF-PARIS 


bandages  for  a  plaster  splint  for  the  leg  or  thigh.  An  advantage 
in  making  one's  own  bandages  is  that  they  are  made  of  the  desired 
width  and  have  the  proper  amount  of  plaster.  They  are  fresh 
and  more  likely,  therefore,  to  set  readily  upon  being  wet.  If 
many  bandages  are  made  at  a  time,  they  may  be  kept  in  a  tin 
cracker  box.     If  the  closed  box  is  put  in  a  dry  place,  these  band- 


Fig.  614. — Fracture  of  the  elbow  or    orearm.     Application  ot  sheet  wadding  tor  protection. 
Method  of  holding  the  arm  at  a  right  angle. 


ages  will  keep  indefinitely.  Should  the  plaster  become  damp,  the 
bandages  should  be  placed  in  a  warm  oven  until  dry.  It  is  im- 
portant in  making  the  plaster  rollers  to  put  just  enough  plaster 
into  the  bandage  and  to  distribute  the  plaster  evenly  through  the 
meshes  of  the  crinoline.  The  proper  amount  of  plaster  to  put  into 
a  bandage  can  only  be  learned  by  experience  in  making  and  using 
the  bandages.     It  is  a  common  error  to  spread  the  plaster  too 


MAKING    THK    PLASTER    BANDAGE  445 

thicklv.  The  water  in  wliicli  the  bandages  are  dipped  should  be  r^Sj^ 
lukewarm  and  of  sufficient  depth  to  cover  the  bandages  when  set  > 
up  on  end.  The  water  working  its  way  into  the  meshes  of  the 
bandages  displaces  the  air  in  the  bandage,  which  is  indicated  by  the 
bubbles  rising  to  the  surface  of  the  water.  As  soon  as  the  bubbles 
have  stopped  rising  the  plaster  is  thoroughly  wet  throughout  the 
bandage.     Table  salt,  two  teaspoonfuls  to  four  quarts  of  water, 


Fig.  615.— Fracture  of  the  elbow  or  forearm.     Application  of  plasterof-Paris  bandage. 
Method  of  holding  the  arm. 


hastens  the  setting  of  the  plaster.  Its  use,  how^ever,  is  to  be  dep- 
recated, because  the  plaster  has  to  be  applied  too  quickly  for  the 
best  results  in  plaster  work,  and  the  brittleness  of  the  plaster  re- 
sulting from  the  use  of  salt  is  undesirable.  The  plaster  bandage 
should  be  lifted  from  the  w-ater  carefully  with  both  hands  holding 
the  two  ends  so  as  to  retain  as  much  plaster  as  possible  within  the 
roll.     The  bandage  should  then  be  wrung  free  from  water  while 


Fig.  616. — Fracture  of  the  elbow  or  forearm.     Plaster-of-Paris  splint  being  applied.     Elbow 

at  a  right  angle. 


Fig.  617. — Anterior  and  posterior  splints  being  applied  after  having  become  firm  upon  the 
forearm.     For  fracture  of  forearm  bones. 


446 


Fig.  6i8. — Anterior  and  posterior  splints  in  position.     To  be  held  in  place  by  adhesive-plaster 
strips  and  a  bandage.    A  light,  durable,  cheap,  efficient  splint. 


Fig.  619. — A  posterior  splint  for  elbow,  forearm,  and  upper  arm.    It  is  most  comfortable. 

447 


Fig.  620. —  Posterior  elbow  splint  in  position. 


Fig.  621. — Posterior  and  anterior  splints  for  elbow.     Anterior  splint  being  applied. 


w 


Fig.  622. — Anterior  and  posterior  splints  for  the  elbow.     Note  the  additional  plaster  wedge 
being  put  in  place  to  strengthen  the  anterior  splint  at  the  bend  of  the  elbow. 


Fig.  623.— Anterior  and  posterior  plaster  splints  applied.     Most  comfortable  and  efficient  in 
injuries  high  up  the   orearm  and  at  the  elbow  and  lower  part  of  upper  arm. 
29  449 


Fig.  624.— Lateral  or  side  splint  of  plaster-of-Paris  for  the  foot,  ankle,  and  lower  leg. 
Note  shape  of  crinoline.  The  plaster  cream  is  being  poured  from  pitcher  and  evenly  rubbed 
into  the  layers  of  crinoline. 


Foot  Portion.  Leg  Portion. 

Fig.  625.— Lateral  or  side  splint  of  plaster-of-Paris  ready  for  application  to  leg,  ankle,  and  foot. 
Plaster  cream  has  been  thoroughly  rubbed  into  the  meshes  of  the  crinoline. 

450 


Fig.  626.— Lateral  or  side  splint  of  plaster-of-Paris  applied  to  the  inner  side  of  leg,  ankle, 
and  foot.  Held  in  position  ready  for  bandage.  Note  the  perforated  tin  strip  at  the  ankle 
for  greater  strength.     Foot  at  right  angle  with  leg. 


Fig.  627. — Lateral  or  side  splint  of  plaster-of-Paris.     Retentive  bandage  being  applied.    Tin 
reinforcing  strip  seen  at  the  ankle. 


451 


Fig.  628. — Plaster  gutter  to  posterior  surface  of  leg  and  foot,  held  in  place  by  a  few  turns 
of  a  cheese-cloth  bandage.  This  plaster  posterior  splint  is  made  much  as  is  the  lateral  plaster 
splint  for  the  leg  and  foot. 


Fig.  629.- 


-Anterior  and  posterior  plaster  splints  for  injuries  to  the  leg  below  the  knee  and 
about  the  ankle  and  foot.    Anterior  splint  being  applied. 


452 


Fig.  530.— Anterior  and  posterior  leg  splints  applied.    Note  application  of  the  half  cuff  01  plaster 

to  reinforce  the  ankle. 


Fig.  631.— Fracture  of  the  patella.     The  leg  covered  with  sheet  wadding.     The  application 
of  the  plaster-of-Paris  roller. 


45: 


Fig.  632. — Fracture  of  the  patella.     Application  of  the  plaster-of-Paris  1  oiler. 

finished. 


Bandage  being 


Fig.  633. — Fracture  of  the  leg.     Plaster-ofParis  splint  applied  from  the  toes  to  the 
Foot  at  aright  angle]withjhe  leg.     Toes  padded  to  prevent  chafing. 


454 


Fig.  634.— Fracture  of  the  leg.     Plaster  cast  of  leg  from  toes  to  below  the  knee  removed. 


Fig-  635.— Fracture  of  the  leg.     Removable  plaster  cast  of  leg.     Same  as  figure  6J4.    Anterior 
view,  showing  cut  in  plaster. 

455 


Fig.  636. — Open  fracture  of  the  leg.     Plaster-of-Paris  splint.    Window  cut  in  plaster,  through 
which  wound  is  dressed.    Window  surrounded  by  oiled  silk. 


Fig.  637. — Open  fracture  of  the  ankle.    Window  in  plaster-of-Paris  splint,  through  which 
wound  is  dressed.     Gauze  seen  in  the  window.     Oiled  silk  about  the  window. 


456 


APPLYING  THE  PLASTER  BANDAGE 


457 


the  hands  still  grasp  its  ends.  The  bandage  should  be  wrung  until 
it  does  not  drip.  In  the  application  of  the  plaster  splint  to  frac- 
tures of  any  part  of  the  body  it  is  ini]ic)rtant  that  all  deformity 
should  be  corrected  and  that  the  part  should  be  thoroughly  immo- 
bilized. This  necessitates  the  presence  of  one  or  two  assistants. 
In  applying  a  plaster  splint  with  the  roller  bandage  the  surgeon 


Fig.  638.— Ham  splint  of  plaster-of-Paris.  The  splint  is  slightly  thicker  at  the  ham 
underneath  the  region  touched  by  the  thumb  in  the  plate.  It  is  thus  strengthened.  More 
comfortable  than  ordinary  wooden  ham  splint. 


should  do  his  work  so  carefully  that  he  scatters  no  plaster  any- 
where but  upon  the  splint  and  in  the  pail  of  water.  The  surgeon 
should  work  neatly.  The  patient  should  be  protected  by  a  sheet. 
The  floor  should  be  protected  by  a  sheet  spread  under  the  patient 
and  under  the  chair  of  the  smgeon.  The  surgeon  should  remove 
his  coat,  roll  up  his  sleeves,  and  be  protected  from  unexpected 
spattering  of  plaster  by  an  apron  or  sheet  over  his  body. 


458 


THE    EMPLOYMENT   OF   PLASTER-OF-PARIS 


One  thickness  of  sheet  wadding  torn  into  strips,  from  three  to 
five  inches  wide,  and  rolled  into  roller  bandages  and  then  applied 
to  the  limb  forms  the  best  protection  to  the  skin  in  applying  the 
plaster  splint.  The  sheet  wadding  is  purchased  at  any  of  the  dry- 
goods  stores.  It  may  be  purchased  by  the  quarter  bale  or  by  the 
single  sheet.  The  plaster  bandage  should  be  applied  to  the  pro- 
tected part  slowly,  deliberately,  and  accurately.  The  bandage 
should  be  applied  smoothly,  and  should  have  no  wrinkles  or  thick 
awkward  places  an^^where.     It  is  well  to  rub  the  bandage  as  fast  as 


Fig.  639.— Fracture  of  the  patella.     Leather  knee-cap  with  hooks  for  lacing.     Made  from 
plaster  cast.     Worn  as  a  protection  to  knee  after  fracture. 


it  is  laid  upon  the  part  with  the  palm  of  the  hand  slightly  wet  to 
distribute  the  plaster  cream  thoroughly  and  evenly.  Over  bony 
prominences  the  bandage  should  be  very  carefully  molded.  This 
will  insure  a  good  fit  and  less  likelihood  of  slipping  upon  change  of 
position.  It  is  well  to  carry  the  first  roll  of  plaster  as  far  as  it  will 
go,  one  or  two  layers  thick,  completing  the  whole  splint  once,  and 
then  to  go  over  it  again  from  beginning  to  end.  A  sufficient  num- 
ber of  layers  should  be  applied  to  make  a  firm  enough  splint  for  the 
support  of  the  part  when  the  plaster  has  set.  The  splint  should 
be  as  light  as  is  compatible  with  strength.     Light  splints,  if  accu- 


APPLYING    THE    PLASTER    BANDAGE 


459 


rately  fitted,  accomplish  more  good  than  heavy,  ill-fitting  ones. 
It  is  better  to  use  too  few  rolls  of  plaster  bandage  rather  than  so 
many  that  a  heavy  and  cumbersome  splint  is  made.  Immediately 
after  the  plaster  has  set,  if  it  is  found  to  be  too  weak  at  any  spot, 
an  additional  bandage  may  be  used  to  reinforce  at  that  point.  The 
part  bandaged  should  be  held  in  perfect  position  until  the  plaster 
has  set  firmly  enough  to  support  it.  This  will  ordinarily  occur  in 
about  ten  or  fifteen  minutes.  The  weight  of  the  splint  may  be 
materially  reduced  by  using  tin  strips  incorporated  in  the  layers  of 


Fig.  640. — Fracture  of  the  leg.     Removable 
dextrin  splint  with  hooks  and  lacing. 


Fig.  641. — Fracture  of  the  leg.    Same  as 
figure  640.    Anterior  view. 


the  plaster  bandage.  These  strips  should  be  perforated  by  holes 
so  as  to  offer  rough  places  to  catch  in  the  plaster  bandage.  The 
two  ends  of  the  splint  should  be  so  finished  that  pressure  and  con- 
sequent deformity  can  not  occur — for  instance,  the  plaster  of  the 
forearm  should  stop  just  short  of  the  bend  of  the  elbow.  The 
plaster  of  the  thigh  should  be  so  far  below-  the  perineum  and  groin 
as  to  permit  of  flexion  of  the  thigh  upon  the  trunk  without  excoriat- 
ing the  skin  of  the  groin.  The  toes  and  fingers  should  be  left 
uncovered  to  admit  of  inspection. 

A  certain  degree  of  skill  is  demanded  upon  the  part  of  the  surgeon 


460  THE    EMPLOYMENT    OF    PLASTER-OF-PARIS 

for  the  proper  application  of  the  plaster-of- Paris  splint.  Plaster- 
of-Paris,  when  used  for  fractured  bones,  is  applied  either  before 
or  after  the  swelling  has  taken  place :  if  applied  before,  it  constricts 
the  seat  of  fracture,  prevents  swelling,  and  may  cause  great  pain ; 
if  applied  after  the  swelling  has  taken  place,  it  becomes  loose  as 
soon  as  the  swelling  of  the  soft  parts  subsides,  and  motion  of  the 
limb  in  the  splint  and  of  the  fragments  of  the  fractured  bone  one 
upon  the  other  is  possible.  It  is  important,  therefore,  to  split  the 
plaster  soon  after  it  has  been  applied,  and  thus  obviate  these  dan- 
gers of  too  light  and  too  loose  a  splint.  The  tightness  of  the  splint 
should  be  regulated  by  straps  and  a  bandage  of  cheese-cloth. 

The  Removal  of  the  Plaster  Splint. — The  removal  of  the  plaster 
splint  is  difficult.  No  instrument  has  been  devised  that  is  more 
efficient  than  an  ordinary  sharp  jack-knife.  If  the  plaster  splint 
is  split  immediately  after  its  application, — i.  e.,  as  soon  as  it  is 
hard, — it  will  be  far  easier  than  if  it  is  cut  after  it  is  thoroughly 
dry.  A  strip  of  tin  an  inch  wide  laid  upon  the  protected  leg  and 
covered  by  the  plaster  in  its  application  will  often  be  of  great  ser- 
vice upon  removing  the  plaster.  The  tin  will  serve  as  a  protection 
to  the  skin,  and  the  cutting  may  be  done  more  quickly  and  easily. 

After  removing  most  of  the  plaster  from  his  hands  the  surgeon^ 
should  wash  his  hands  with  a  little  water  and  granulated  sugar  or 
molasses.  The  sugar  assists  in  removing  all  traces  of  plaster  and 
leaves  the  skin  soft  and  clean.  Bandages  of  plaster-of- Paris  are  so 
readily  obtained,  so  efficient,  so  safe  from  interference  upon  the 
part  of  the  patient,  and  so  easy  to  apply,  that  it  is  surprising  they 
are  not  applied  more  often  than  they  are. 

The  dextrin  bandage  is  much  slower  in  becoming  firm  than  the 
plaster  bandage,  and  yet  is  very  light  and  serviceable.  It  is  applied 
exactly  as  is  the  plaster-of- Paris  bandage.  The  roller  bandage 
of  cotton  cloth  is  first  unrolled  and  rerolled  in  a  basin  containing  a 
watery  solution  of  powdered  dextrin.  Formula  for  making  the 
solution  of  dextrin :  Add  about  fourteen  ounces  of  powdered  dex- 
trin to  a  pint  of  water,  boil  until  dissolved,  strain,  and  add  one 
ounce  of  alcohol.  The  bandage  is,  therefore,  thoroughly  saturated 
with  the  dextrin  solution.  After  covering  the  part  bandaged  once, 
dextrin  is  painted,  with  a  small  paint-brush,  over  the  bandage. 
This  is  allowed  to  dry  before  a  second  and  a  third  layer  of  the  band- 


THE    DEXTRIN    BANDAGE  46 1 

age  are  applied.     After  each  bandage  a  coating  of  dextrin  is  ap-      '^1^^^ 
plied.     After  the  final  bandage  several  coatings  of  dextrin  are  ap-        jji^iD 


plied,  until  a  shiny,  smooth  surface  results.     This  bandage  may 
be  cut,  and,  by  the  addition  of  strips  of  leather  along  the  cut  edge 
upon  which  are  hooks,  may  be  laced  and  unlaced  as  necessary        j 
(see  Figs.  615,  616) 


CHAPTER  XX 
THE  AMBULATORY  TREATMENT  OF  FRACTURES 

By  the  ambulatory  treatment  of  fractures  of  the  lower  extrem- 
ity is  understood  a  method  of  treatment  that  permits  the  imme- 
diate and  continued  use  of  the  injured  limb  as  a  means  of  locomo- 
tion. 

Medical  literature  contains  many  references  to  this  method.  It 
has  been  in  use  for  some  ten  years.  It  has  not  met  with  general 
acceptance  even  among  hospital  surgeons.  It  is  a  radical  method 
and  open  to  criticism.  It  contains,  however,  several  important 
suggestions.  It  will  prove  instructive  to  follow  the  adoption  of 
this  method  by  its  advocates,  and  to  discover,  if  possible,  what 
there  is  in  it  of  permanent  value. 

Orthopedic  surgeons  as  early  as  1878  conceived  the  idea  of 
allowing  a  patient  with  a  fracture  of  the  thigh  or  of  the  leg  to  walk 
about  by  means  of  apparatus.  Thomas,  of  Liverpool,  and  Dow- 
browski  used  the  Thomas  knee-splint  in  the  treatment  of  fractures 
certainly  as  early  as  the  year  1881  or  1882.  Krause,  a  German 
surgeon,  published,  in  1891,  the  first  account  of  the  treatment  of 
fractures  of  the  bones  of  the  leg  in  walking  patients.  Krause 
demonstrated  that  plaster-of- Paris  could  be  used  as  a  splint  in 
fractures  of  the  leg  and  in  transverse  fractures  of  the  thigh. 
Korsch,  in  1894,  presented  a  paper  to  the  German  Surgical  Con- 
gress demonstrating  that  compound  fractures  of  the  leg  and  frac- 
tures of  the  thigh  may  be  treated  with  plaster-of- Paris  splints  and 
early  use.  Korsch  makes  permanent  extension  in  a  thigh  frac- 
ture, while  traction  is  maintained  by  an  assistant,  by  applying  the 
plaster  directly  to  the  skin,  snugly  to  the  malleoli,  the  dorsum  of 
the  foot,  and  the  heel.  A  padded  ring  is  incorporated  into  the 
upper  limit  of  the  plaster  splint  around  the  thigh,  which  presses 
against  the  tuberosity  of  the  ischium,  and  thus  accomplishes  coun- 
terextension.     Korsch's  cases  were  treated  in  Bardeleben's  clinic. 

462 


HISTORICAL   CONSIDERATIONS  463 

Bruns,  of  Tubingen,  in  1893,  described  a  splint  for  use  in  these  cases 
of  fracture  of  the  leg  and  thigh.  Dollinger,  of  Budapest,  in  1893, 
described  a  splint  for  the  ambulators'  treatment  of  fractures  of 
both  bones  of  the  leg,  and  reported  three  cases.  Bollinger's 
method  of  applying  the  plaster-of-Paris  splint  is  the  one  generally 
used  whenever  the  ambulators'  treatment  is  employed.  The 
method  is  described  later. 

Warbasse,  at  the  Methodist  Episcopal  Hospital  of  Brooklyn, 
N.  Y.,  in  1893,  was  the  first  in  this  countrx'  to  adopt  systematically 
Bollinger's  method.  Warbasse  reports  six  cases — all  in  young 
adults.  Bardeleben  reported,  in  1894,  one  hundred  and  sixteen 
cases  treated  with  walking  splints.  There  were  eighty-nine  frac- 
tures of  the  leg,  complicated  and  uncomplicated ;  five  fractures  of 
the  patella ;  twenty -two  fractures  of  the  thigh,  five  of  which  were 
compound ;  three  cases  of  osteotomy  for  genu  valgum.  Bardele- 
ben lays  down  the  following  law :  "  It  is  of  the  greatest  advantage 
to  the  patient  that  such  a  dressing  can  be  applied  to  the  broken  leg 
that  he  can  bear  the  weight  of  the  body  upon  it  and  walk  about; 
but  such  a  method  of  treatment  should  be  applied  only  under  medi- 
cal supervision,  and  with  the  most  careful  consideration  of  compli- 
cations that  might  arise."  Korsch  presented  to  the  German  Sur- 
gical Congress,  in  1894,  seven  cases — ^three  of  the  thigh  and  four  of 
the  leg.  Albers,  in  1894,  reported  seventy-eight  cases  (fifty -six  of 
the  leg,  five  of  the  patella,  sixteen  of  the  thigh,  and  one  of  the  leg 
and  thigh)  treated  by  the  ambulatory  method.  He  seems  to  be  a 
little  more  cautious  than  other  German  surgeons  in  this  matter. 
He  savs  that  when  great  pain  is  present,  it  is  best  to  employ  injec- 
tions of  morphin. 

Elevation  of  the  limb  will  often  reduce  the  swelling ;  when  this 
does  not  suffice,  the  bandage  must  be  removed.  Severe  local  pain 
from  presstu-e  indicates  the  necessity  for  cutting  a  fenestrum.  The 
first  attempt  at  walking  should  be  made  on  the  day  following  the 
application  of  the  cast.  A  crutch  and  cane  are  used  at  first ;  later, 
two  canes  are  emplo^'ed ;  and,  finally,  some  patients  walk  without 
any  support  at  all.  Krause,  in  1894,  reported  seventy-two  cases 
treated.  He  is  of  the  opinion  that  the  ambulatory  treatment  in 
plaster  splints  must  be  limited  principally  to  fractures  and  osteot- 
omies in  the  region  of  the  malleoli,  the  leg,  and  the  lower  end  of 


464  THE   AMBULATORY    TREATMENT    OF    FRACTURES 

the  thigh.  He  does  not  employ  the  method  in  the  handHng  of 
obhque  fracture  of  the  femur  and  fractures  of  the  neck  of  the 
femiur.  Bardeleben  writes  again  in  1895,  reporting  up  to  that  date 
one  hundred  and  eighty-one  cases  treated  by  the  ambulatory 
treatment.  This  last  report,  of  course,  included  the  one  hundred 
and  sixteen  cases  of  the  previous  record.  Dr.  Edwin  Martin,  be- 
fore the  Surgical  Section  of  the  College  of  Physicians  of  Philadel- 
phia, in  December,  1895,  reported  twenty  cases  of  fracture  of  the 
leg  treated  by  this  method.  Dr.  E-  S.  Pilcher,  of  Brooklyn,  N.  Y., 
in  whose  wards  Marbasse  worked,  reported  to  the  American  Sur- 
gical Association  the  twenty  or  more  cases  treated  by  him  in 
which  the  results  were  satisfactory.  N.  P.  Dandridge,  of  Cincin- 
nati, Ohio,  has  used  the  method  in  eight  cases.  In  most  of  the 
cases  pain  was  complained  of  when  weight  was  borne  on  the  foot. 
In  a  feeble  woman  it  was  necessary  to  remove  the  cast  in  the  third 
week.  In  the  case  of  a  man, — a  compound  fracture  of  the  leg, — 
after  walking  two  weeks  he  had  so  much  pain  that  the  plaster  was 
removed.  Redness  and  swelling  were  great  at  the  seat  of  fracture, 
and  there  was  much  swelling  over  the  internal  malleolus.  Wood- 
bury introduced  the  method  at  Roosevelt  Hospital,  New  York 
city,  and  Fiske  has  reported  cases  treated  at  that  clinic.  Roberts, 
of  Philadelphia,  and  Woolsey,  of  New  York,  have  used  the  method 
in  selected  cases  with  satisfaction.  A.  T.  Cabot,  of  Boston,  has 
used,  in  several  fractures  of  the  femur,  Taylor's  long  hip-splint. 
E.  H.  Bradford,  of  Boston,  has  treated  cases  of  fracture  at  the 
Children's  Hospital  by  a  modified  Thomas  knee  splint,  with  and 
without  plaster-of- Paris  splinting  (Fig.  642). 

Those  advocating  the  ambulator}'  treatment  suggest  its  appli- 
cation to  fractures  of  the  leg  below  the  knee,  both  simple  and  com- 
pound, and  in  fractures  of  the  lower  end  of  the  femur.  The  appa- 
ratus is  not  to  be  applied  for  three  or  four  days  if  there  is  much 
primary  swelling. 

The  method  of  application  of  the  plaster  splint  in  the  ambu- 
latory treatment  of  fractures  of  the  tibia  and  fibula  alone  is  as 
follows  (this  is  practically  the  method  of  Dollinger) :  First  comes 
the  cleansing  of  the  skin  of  the  leg  with  soap  and  water  and  then 
the  reduction  of  the  fracture.  Then,  with  the  foot  fixed  at  a  right 
angle  to  the  leg,  a  flannel  bandage  is  smoothly  and  evenly  applied 


THE    METHOD    APPIJED    TO    THIC    TIHIA    AND    FIBULA 


46; 


from  the  toes  to  just  above  tlie  knee.  This  bandage  is  made  to 
inehide  beneath  the  sole  of  the  foot  a  padding  of  ten  or  fifteen 
la\'ers  of  cotton  wadding,  making  a  pad  about  three-fourths  of  an 
inch  thick,  after  it  is  compressed  by  the  moderate  pressure  of  the 
flannel  bandage.  Over  this  is  now  applied  the  plaster  bandage 
from  the  base  of  the  toes  to  just  above  the  knee,  especial  care  being 


IL 


a 


{r. 


Fig.  642. — Thomas  knee  splint  or  ambulatory  treatment  of  leg  fractures,  used  with  a  light 
plaster-of-Paris  leg  splint :  a,  ordinary  form;  b,  "caliper"  or  convalescent  splint  so  fitted  as 
to  keep  the  heel  of  the  foot  away  from  the  boot  while  the  toes  are  used  ;  c,  rtie  half-ring 
sometimes  used  at  the  upper  end ;  d,  lower  end  of  splint,  as  arranged  for  windlass  traction. 


taken  that  the  application  is  made  smoothly  and  somewhat  more 
firmly  than  is  the  custom  in  the  ordinary  plaster  cast.  The  layers 
of  the  bandage  should  be  well  rubbed  as  they  are  applied,  with  a 
view'  to  obtaining  the  greatest  amount  of  firmness  with  the  smallest 
amount  of  material.  The  sole  is  strengthened  by  incorporating 
with  the  circular  turns  an  extra  thickness  composed  of  ten  or 


466  THE    AMBULATORY    TREATiMENT   OF    FRACTURES 

twelve  layers  of  bandage  well  rubbed  together,  and  extending 
longitudinally  along  the  sole.  The  bandage  is  applied  especially 
firmly  about  the  enlarged  upper  end  of  the  tibia,  and  here  it  is 
made  somewhat  thicker.  As  it  dries  it  may  be  pressed  in  so  as  to 
conform  more  closely  to  the  leg  just  below  the  heads  of  the  tibia 
and  fibula.  The  assistant  who  stands  at  the  foot  of  the  table  and 
supports  the  leg  makes  such  traction  or  pressure  as  is  required  to 
keep  the  fragments  in  proper  position  while  the  plaster  is  being 
applied.  The  operation  requires  about  twenty  minutes,  and  by 
the  time  the  last  bandage  is  applied  the  cast  should  be  fairly 
hard. 

It  is  seen  that  when  this  cast  has  become  hardened  the  leg  is 
suspended.  When  the  patient  steps  upon  the  sole  of  the  plaster 
cast,  the  thickness  of  the  cotton  beneath  the  foot  separates  the  sole 
of  the  foot  so  far  from  the  sole  of  the  cast  that  the  foot  hangs  sus- 
pended in  its  plaster  shoe.  Thus  the  weight  of  the  body,  which 
would  come  upon  the  foot,  is  borne  by  the  diverging  surface  of  the 
leg  above  the  ankle.  The  chief  of  these  is  the  strong  head  of  the 
tibia.  A  lesser  role  is  played  by  the  head  of  the  fibula  and  the 
tapering  calf  in  muscular  subjects. 

In  thigh  fractures  the  use  of  the  long  Taylor  hip-splint,  together 
with  a  high  sole  upon  the  well  foot  and  crutches,  is  generally  ac- 
cepted as  the  best  method  of  ambulatory  treatment. 

The  advantages  claimed  for  the  ambulatory  method  are : 

Time  is  saved  to  the  business  man  by  this  method — he  having 
to  give  up  but  about  seven  days  to  a  fracture  of  the  leg.  The  time 
spent  by  the  patient  in  the  hospital  is  less  than  by  other  methods. 
The  general  health  is  conserved;  whereas  by  the  old  method  the 
appetite  is  variable,  sleep  is  troubled,  the  bowels  are  constipated, 
and  general  discomfort  prevails.  There  is  greater  general  comfort 
by  this  method  than  by  any  other.  In  drunkards  and  those  with 
a  tendency  to  delirium  tremens  this  liability  is  greatly  diminished. 
In  old  people  the  danger  of  a  hypostatic  pneumonia  is  lessened. 
The  primary  swelling  associated  with  a  fracture  is  often  avoided, 
and  always  less  than  by  the  older  methods.  The  secondary  edema 
and  muscular  weakness  are  less.  The  functional  usefulness  of  the 
whole  leg  is  greater.  There  is  less  atrophy  of  the  muscles  of  the 
thigh  and  leg.     The  amount  of  the  callus  is  diminished.     There  is 


THE   ADVANTAGES   CLAIMED   FOR   THE   METHOD  467 

less  stiffness  of  neighboring  joints.     Union  in  a  fracture  occurs  at 
an  earlier  date. 

Before  this  method  can  be  adopted  generally  and  in  hospital 
treatment  it  must  be  demonstrated  that  it  is  safe,  and  that  it 
offers  chances  of  better  functional  results  than  are  obtained  under 
present  methods,  and  that  the  minor  advantages  claimed  for  it  by 
ardent  German  advocates  are  real  and  not  iniaginar\'.     The  first 
great  advantage  of  the  method  is  stated  to  be  that  the  stay  in  the 
hospital  and  the  time  away  from  one's  occupation  are  much  les- 
sened.    Regarding  this  point  the  Massachusetts  General  Hospital 
Surgical  Records  were  consulted  for  these  three  periods:  before 
the  use  of  plaster-of- Paris — that  is,  previous  to  1S65;  just  at  the 
beginning  of  the  use  of  plaster-of- Paris  as  a  splint  for  fracture,  and 
in  1895,  1896,  and  1S97.     Thirty-five  unselected  cases  of  fracture 
of  the  tibia  and  fibula  were  tabulated  from  each  period.     The 
dm-ation  of  the  average  time  spent  in  the  hospital  in  the  first 
period— z".  e.,  previous  to  1865— was  forty-six  days;  in  the  second 
period— z.  e.,  about  1866— it  was  forty-five  days;  at  the  present 
time  it  is  sixteen  days.     In  the  second  period  plasters  were  applied 
to  fractured  legs  on  an  average  at  about  the  twenty-eighth  dav ;  at 
the  present  time,  on  the  fourteenth  day.     In  other  words,  there 
has  been  since  the  introduction  of  the  plaster  splints  a  graduallv 
shorter  detention  in  the  hospital,  as  surgeons  have  come  to  recog- 
nize the  safety  of  an  earlier  application  of  a  fixed  dressing.     On  an 
average,  patients  with  fracture  of  the  leg  are  detained  in  the  hospi- 
tal to-day  but  sixteen  days.     The  vers'  great  saving  to  the  hospital 
in  time  by  the  ambulator}-  treatment  does  not,  therefore,  appear. 
It  is  impossible  to  consider  the  statements  made  with  regard  to 
rapidity  of  healing,  sign  of  callus,  absence  of  muscular  atrophy, 
and  absence  of  rigidity  of  joints,  because  there  are  no  facts  availa- 
ble for  the  purpose.     The  advantages  stated  are  based,  most  of 
them,  upon  the  personal  impressions  of  the  surgeon  in  charge; 
impressions  compared  with  scientific  observations  are  imtrust- 
worthy. 

Krause  presents  a  table  from  Paul  Bruns  containing  the  average 
periods  of  healing  in  a  series  of  fractures,  and  compares  these 
periods  with  his  own  fracture  cases  treated  by  the  ambulators- 
method.    This  is  the  only  attempted  scientific  statement  of  obser- 


468  the;  ambulatory  treatment  oe  fractures 

vation  on  this  important  point.  Krause  concludes  from  a  study 
of  these  tables  that,  "In  the  treatment  of  fractures  of  the  middle 
and  upper  thirds  of  the  leg,  the  ambulatory  method  shows  a  great 
advantage  in  the  period  of  consolidation  as  well  as  in  the  time 
when  the  patient  can  return  to  work.  It  seems  that  the  higher  up 
the  fracture  is  in  the  leg,  the  sooner  a  cure  is  effected  by  the  ambu- 
latory method  of  treatment." 

Conclusions. — A  review  of  the  literature  does  not  disclose  any 
other  advantage  in  the  results  of  the  ambulator}^  treatment  over 
the  present  treatment  of  fractures  of  the  leg  than  that  stated  by 
Krause.  The  present  commonly  accepted  method  of  treating 
fractures  of  the  femur  by  long  rest  in  the  horizontal  position,  with 
extension  by  weight  and  pulley,  is  not  satisfactorv^  The  pro- 
tracted stay  in  bed  is  undesirable.  The  use  of  the  Taylor  hip-splint 
in  the  treatment  of  this  fracture,  assisted  by  coaptation  splints  or  a 
splint  of  plaster-of- Paris,  is  of  distinct  value.  This,  however,  is  a 
somewhat  well-known  method  of  ambulatory  treatment. 

Theoretically  and  practically,  the  ambulator)'  treatment  does 
not  perfectly  immobilize;  therefore,  it  can  not  preeminently  suc- 
ceed as  a  means  of  treatment.  The  method  in  general  seems  to 
be  unsurgical.  Embolism,  both  of  fat  and  of  blood,  and  the  likeli- 
hood of  pressure-sores  in  the  use  of  the  plaster  splint  are  dangers  to 
be  considered.  It  is  wise  to  allow  the  injured  limb  to  rest  while 
the  reparative  process  is  beginning.  Muscular  relaxation  is  de- 
sirable in  the  treatment  of  fractures.  The  very  admission  by  the 
advocates  of  the  ambulatory  treatment  that  muscular  contrac- 
tions take  place  is  reason  enough  for  supposing  that  complete 
immobilization  is  not  obtained  by  this  method.  However,  in  cer- 
tain carefully  selected  cases  of  fracture  below  the  knee,  particu- 
larly of  the  fibula,  if  under  the  care  of  a  competent  and  skilful  sur- 
geon, it  is  possible  to  conceive  of  the  ambulatory  method  being 
used  without  doing  harm. 

A  consideration  of  the  ambulatory  treatment  of  fractures  should 
lead  to  a  more  careful  and  early  use  of  the  pi  aster-of- Paris  splint 
in  fractures  of  the  leg,  and  to  a  proper  application  of  the  long  hip- 
splint  or  its  equivalent  in  fractures  of  the  thigh,  and  to  the  early 
use  of  crutches  and  the  high  sole  on  the  well  foot  in  both  of  these 
lesions. 


the  advantages  claimed  for  the  method  469 

Materials  for  the  Ordixarv  Care  of  Closed  Fractures 

The  materials  with  which  a  physician  should  be  provided  in 
order  to  properlv  care  for  the  fractures  ordinarily  met  with  are 
comparatively  few. 

There  is  scarcely  a  fracture  which  can  not  be  treated  satisfac- 
torilv  bv  the  proper  use  of  plaster-of- Paris. 

Plaster-of- Paris  roller  bandages. 

^^'ashed  crinoline  or  the  common  cheese-cloth  gauze  roller 
bandage. 

Plaster-of-Paris. 

A  jack-knife  for  splitting  plaster  dressings. 

A  pair  of  heavy  scissors. 

Thin  splint  wood,  -^  of  an  inch  in  thickness. 

Iron  wire,  j  of  an  inch  in  diameter. 

Posterior  wire  splint,  for  adult  leg. 

Anterior  wire  splint,  for  adult  leg. 

Siugeon's  adhesive  plaster. 

Cotton  and  cheese-cloth  roller  bandages. 

Sheet  wadding  for  padding  splints. 


BIBLIOGRAPHY 

The  important  contributions  to  literature  wliicli  have  been  consulted  are  recorded 
below  Dr  Stimson's  book  upon  "  Fractures  "  will  always  stand  as  a  classical  work 
in  its'especial  field.  Dr.  Poland's  work  upon  "The  Epiphyses  is  also  a  very 
valuable  contribution  to  fracture  literature.  The  text  has  been  kept  free  of  all 
references  in  order  that  greater  clearness  might  result. 


Hamilton,  Fractures  and  Dislocations. 

Stimson,  A  Practical  Treatise  on  Fractures  and  Dislocations,  Lea  Bros.,  1899. 

Helferich,  Atlas  of  Traumatic  Fractures  and  Luxations,  with  a  Brief  Treatise,  Wm. 

Wood  &  Co.,  1896. 
Roberts,  P.  Blakiston,  Son  &  Co.,  Philadelphia,  1897. 
Wharton  and  Curtis,  The  Practice  of  Surgery. 

The  International  Encyclopedia  of  Surgery  ;  supplementary  volume  vii,  1895. 
Dennis,  F.  S.,  System  of  Surgery,  1895. 
Cheever,  Lectures  on  Surgery,  Damrell  and  Upham,  Boston,  1894. 

FRACTURE  OF  THE  SKULL 
Huguenin,  Cyclopaedia  practische  Medicin,  Ziemssen,  Band  xii,  1897. 
Mills,  The  Nervous  System  and  Its  Diseases,  1898. 
Bradford  and  Smith,  Transactions  of  the  American  Surgical  Association,  volume 

LX,  page  433.  _ 

Bullard,  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  1897. 
Dana,  Text-book  of  Nervous  Diseases. 

Courtney,  Boston  Medical  and  Surgical  Journal,  April  6,  1S99,  page  345. 
Hill  and  Bayliss,  Journal  of  Physiology,  London,  1895,  xvui,  page  324. 
Walton,  American  Journal  of  Medical  Sciences,  September,  1898. 
Putnam,  Walton,  Scudder,  Lund,  American  Journal  of  ^ledical  Sciences,  April 

1S95. 
Phelps,  Traumatic  Injuries  of  the  Brain. 

FRACTURE  OF  THE  NASAL  BONES 
Bosworth,  Diseases  of  Nose  and  Throat,  third  edition,  pages  157-161. 
Zuckerkandl,  Anat.  norm,  et  Patholog.  des  Fosses  Nasales,  volume  I,  page  429- 
Evans,  Deflections  of  the  Nasal  Septum,  Louisville  Journal  of  Surgerv-  and  Medi- 
cine, volume  V,  June,  1898,  pages  I-4. 
Casselberry,   Deformities  of   the  Septum    Narium,  Transactions  of   the  American 

Medical  Association,  volume  XXII,  No.  9,  pages  469-471. 
Cobb,  Fracture  of  the  Nasal  Bones,  Journal  of  the  American  Medical  Association, 

volume  XXX,  1898,  page  588. 
Freytag,  Monatschrift  fiir  Ohrenheilkunde,  1896,  Band  xxx,  Seiten  217-224. 

471 


472  BIBLIOGRAPHY 

Zuckerkandl,  Anatomic  der  Nasenhohle,  Band  n. 

Watsin,  Lancet,  1896,  volume  I,  page  972. 

Roe,  The  American  Medical  Quarterly,  June,  1899. 

FRACTURE  OF  THE  SPINE 

Thorburn,  A  Contribution  to  the  Surgery  of  the  Spinal  Cord. 

Walton,  Boston  Medical  and  Surgical  Journal,  December  7,  1893.      The  Journal  of 

Nervous  and  Mental  Diseases,  January,  1902. 
Thomas,  Boston  Medical  and  Surgical  Journal,  September  7,  1899,  page  233. 
Dennis,  Annals  of  Surgery,  March,  1895. 

Burrell,  Transactions  of  the  Massachusetts  Medical  Society,  1887. 
Taylor,  Journal  of  the  Boston  Society  of  the  Medical  Sciences,  December,  1898. 
Wagner  and  Stolper,  Die  Verletzungen  des  Wirbelsaule  und  des  Riickenmarks, 

1898,  Seite  415. 
Kocher,  Mittheilungen  Grenzgebieten  der  Medicin  und  Chirurgie,  1896. 
White,  Transactions  American  Surgical  Association,  vol.  IX. 
Cheever,  Boston  Medical  and  Surgical  Journal,  September  28,  1893. 
Pilcher,  Annals  of  Surgery,  volume  XI,  pages  187-200. 
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FRACTURE  OF  THE  SCAPULA 

Blake,  Boston  City  Hospital  Reports,  1899,  page  368. 

FRACTURE  OF  THE  HUMERUS 
Bruns,  Deutsche  Chirurgie,  Theil  28,  2.  Halfte. 
Murray,  New  York  Medical  Journal,  June  25,  1892. 

Monks,  Boston  City  Hospital  Medical  and  Surgical  Reports,  1895;  also  Boston 
Medical  and  Surgical  Journal,  March  21,  1895,  January  9,  1896,  and  December 

4,  1895- 
Lund,  Boston  City  Hospital  Reports  for  1897,  page  389. 

AUis,  Annals  of  the  Anatomical  and  Surgical  Society,  Brooklyn,  1880,  II,  289. 
Smith,  Boston  Medical  and  Surgical  Journal,  July,  1895. 
Stimson,  Roberts,  Allis,  Transactions  of  the  American  Surgical  Association,  1881 

to  1898. 

FRACTURE  OF  THE  FOREARM 

Pilcher,  Paper  read  to  Association  of  Military  Surgeons  of  the  United  States,  Berlin 
Printing  Co.,  Columbus,  Ohio.  Medical  Record,  1878,  II,  74.  Annals  of  An- 
atomical and  Surgical  Association,  Brooklyn,  1887,  ill,  page  33. 

Moore,  Transactions  of  the  Medical  Society,  State  of  New  York,  1880. 

Bolles,  Boston  City  Hospital  Reports,  third  series,  1882,  page  340. 

Conner,  Journal  of  the  American  Medical  Association,  1894,  page  54- 

Roberts,  Medical  News,  1890,  LVii,  615.      Annals  of  Surgery,  1892,  xvi. 

Mouchet,  A.,  Revue  de  Chirurgie,  May,  1900. 

FRACTURE  OF  THE  THIGH 

Cabot,  Boston  Medical  and  Surgical  Journal,  January  3,  1S84,  page  6. 
Allis,  Transactions  of  the  American  Surgical  Association,  volume  ix,  1891,   page 
329.     Medical  News,  November  21,  1891. 


BIBLIOGRAPHY  473 

Hutchinson,  Lancet,  1S98,  11,  1630. 

Packard,  International  Encyclopaedia  of  Surgery. 

Whitman,  Annals  of  Surgery,  June,  1897,  page  I. 

Senn,  Journal  of  the  American  Medical  Association,  August  3,  1889. 

Ridlon,  Transactions  of  the  American  Orthopedic  Association,  1887,  page  186. 

Lane,  Medicochirurgical  Transactions,  London,  1888. 

Scudder,  Boston  Medical  and  Surgical  Journal,  March  22,  29,  1900. 

SEPARATION  OF  THE  LOWER  EPIPHYSIS  OF  THE  FEMUR 
Annals  of  Surgery,  Philadelphia,  1898,  XXVIII,  664. 
Annals  of  f  lynecolog}',  November,  1S90.  • 

British  Medical  Journal,  December,  1894,  page  671. 
New  York  Medical  Record,  October  5,  1895. 
Annals  of  Surgery,  March,  1896. 

Archives  Generales,  March  and  April,  1884,  volume  xiii,  page  272. 
Transactions  of  the  American  Surgical  Association,  1895. 
Liverpool  Medicochirurgical  Journal,  January,  1885,  page  41. 
Liverpool  Medicochirurgical  Journal,  July,  1883. 
Stimson,  Fractures  and  Dislocations,  1899. 
Hutchinson,  Lancet,  May  13,  1899. 

McBurney,  Annals  of  Surgery,  March,  1896,  XXII,  506. 
Harte,  Transactions  of  the  American  Surgical  Association,  1895. 
Deleus,  Archives  Generale  de  Medicine,  1884,  volume  xiii,  page  272. 
Poland,  Traumatic  Separation  of  the  Epiphyses,  1898. 
Smith,  Transactions  of  the  American  Surgical  Association,  volume  VIII. 

FRACTURE  OF  THE  PATELLA 
Powers,  Annals  of  Surgery,  July,  189S. 
Bull,  New  York  Medical  Record,  xxxvii,  1890. 
McBurney,  Annals  of  Surgery,  1895,  xxi,  312. 
Pilcher,  Annals  of  Surgery,  1890,  xii. 

Stimson,  Annals  of  Surgery,  1895,  xxi,  603  ;    1896,  XXiv,  45. 
Cabot,  Boston  Medical  and  Surgical  Journal,  CXXV. 
Dennis,  System  of  Surgery. 

Lund,  Boston  Medical  and  Surgical  Journal,  1896,  CXXXV,  ;^;^S. 
Fowler,  Annals  of  Surgery,  January,  1891. 
Macewen,  Annals  of  Surgerj',  1887,  volume  v,  page  177. 
Phelps,  New  York  Medical  Journal,  June,  1890. 
White,  New  York  Medical  Record,  October  27,  1888. 
Beach,  New  York  Medical  Record,  March  15,  1890. 

FRACTURE  OF  THE  LEG 
Cabot,  The  Boston  Medical  and  Surgical  Journal,  January'  3,  1894,  page  6. 
Lovett,  Boston  City  Hospital  Medical  Reports,  1899,  page  222. 
AUis,  Annals  of  Surgery,  1897. 
Tiffany,  Annals  of  Surgery,  1896,  xxiii,  449. 
Lane,  Transactions  of  the  Clinical  Society,  London,  xxvii,  167. 
Osgood,  Robert,  Transactions  of  the  American  Orthopedic  Association,  1902. 
Stimson,  New  York  Medical  Journal,  June  25,  1892. 


474  BIBLIOGRAPHY 

Smith,  N.  R.,  Treatment  of  Fractures  of  the  Lower  Extremity,   Baltimore,   Kelly 
and  Piet,  1867. 

GUNSHOT  WOUNDS  OF  BONE 
Makins,  Geo.  Henry,  Surgical  Experiences  in  South  Africa,  1899-1900  (volume 

of  486  pages,  published  by  Smith,  Elder  &  Co.,  1901). 
Borden,  W.  C,  The  Use  of  the  Rontgen  Ray  by  the  Medical   Department  of  the 

United   States  Army  in  the  War  with  Spain,  1898,  Government  Printing  Office, 

1900. 
Kocher,  T.,    Zur    Lehre   von    den    Schusswunden    durch    kleinkaliber   Geschosse, 

Cassel,  1895,  Th.  Q.  Fisher  &  Co. 
La  Garde,  Boston  Medical  and  Surgical  Journal,  January  18,  1900,  p.  57  ;   October 

25,  1900.      Report  of  the  Surgeon-General  of  United  States  Army,  1893. 
Dennis,  System  of  Surgery,  volume  I,  p.  460. 
Treves,  F.,  London  Lancet,  1900,  i,  1359. 
Dent,  C,  British  Medical  Journal,  1900,  il,  632  and  634. 
MacCormac,  Sir  Wm.,  London  Lancet,  1900,  i,  1485. 
Thomson,  Sir  Wm.,  British  Medical  Journal,  1901,  11,  265.      London  Lancet,  II, 

1901,  264. 
Nancrede,  Transactions  of  the  American  Surgical  Association,  1899,  1900. 
Hall,  Edward  J.,  London  Lancet,  1901,  i,  130,  1755. 

THE  AMBULATORY  TREATMENT  OF  FRACTURES 

Krause,  Deutsche  medicinische  Wochenschrift,  1891,  No.  13. 

Korsch,  Berliner  klinische  Wochenschrift,  No.  2. 

Bruns,  Beitrage  zur  klinische  Chirurgie,  Band  X,  Heft  il,  18. 

DoUinger,  Centralblatt  fiir  Chirurgie,  1893,  No.  46. 

Warbasse,  Transactions  of  the  Brooklyn  Surgical  Society,  October,  1894. 

Bardeleben,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIIL  Kon- 

gress,  1894. 
Albers,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIIL  Kongress, 

1894. 
Krause,  Verhandlungen  der  deutsche  Gesellschaft  fiir  Chirurgie,  XXIIL  Kongress, 

1894. 
Pilcher,  Transactions  of  the  American  Surgical  Association,  volume  Xiv,  1896. 
Woodbury,  New  York  Medical  Record,  1897. 

Roberts,  Transactions  of  the  American  Surgical  Association,  volume  xiv,  1896. 
Woolsey,  New  York  Medical  Record,  1897. 
Cabot,  New  York  Medical  Record,  1897. 
Bradford,  New  York  Medical  Record,  1897.  , 

THE  EPIPHYSES 

Quain,  Dwight,  Gray,  Morris. 

Poland,- John,  f.R.C.S.,  Traumatic  Separation  of  the  Epiphyses,  1898. 
Briinne,   Das  Verhaltniss  die   Gelenkkapselen  zu  die  Epiphyse   die   Extremitaten- 
Knochen. 

MASSAGE 

Bennett,  W.  H.,  London  Lancet,  June  2,  1900;  London  Lancet,  Feb.  5,  1898. 


INDEX 


Abscess  of  jaw,  61,  71 
Acromial  process  of  scapula,  121 

treatment,  123 
Active  motion  after  Colles'  fracture, 
242 
after  fracture  of  femur,  302 

of  leg,  378 
after  separation  of  lower  epiph- 
ysis of  femur,  321 
in  fracture  of  patella,  337 
Ambulatory  treatment : 

of  fracture  of  shoulder,  143 

of  thigh,  303 
of  fractures,  462 

advantages  claimed,  466 
conclusions,  468 
early  advocates,  462 
materials  for  ordinary  care  of 

closed  fractures,  469 
method  of  application  of  plas- 
ter splint,  464 
reports  of  cases,  463 
American  Surgical  Association,  con- 
clusions expressing  views  of,  upon 
medicolegal    relations    of    X-rays; 
adopted  in  May,   1900,  438 
Anesthetics,  use  of,  in  examination: 
of    anatomical    neck    of    hu- 
merus, 132 
of  Colles'  fracture,  226,  228 
of  elbow,  162,  180,  191 
of  hip,  263 
of  leg,  353,  375 
of  shoulder,  126,  130 
Anesthetics,  use  of,  in  treatment : 
of  Colles'  fracture,  236 
of  fracture  of  carpus,  247 
of  forearm,  201 
of  shaft  of  femur,  286 
of  shaft  of  humerus,   154 
of  surgical  neck  of  humerus, 
141 
of  greenstick  fracture  of  fore- 
arm, 214 
of  open  fracture  of  leg,  375 
of  Pott's  fracture,  387 
Ankylosis  of  ankle-joint,  405 
Arthritis   after   fracture   of   leg,   380 
Asch  tube,  49 


Astragalus,  400 

open  fracture,  404 

treatment,  operative,  405 

treatment,  400 
Atrophy,  muscular,  after  fracture  of 

humerus,  158 


Bandage,  dextrin,  460 
application,  460 
formula,  460 
elastic     rubber,     in     fracture     of 

patella,  330 
flannel,     substituted     for     plaster 

sphnt,  379,  404 
plaster-of-Paris,  441 
Bardeleben,  quoted:  law  concerning 
ambulatory  treatment  of  fractures, 
463 
Base-ball  finger,  257 
Base  of  skull,  26 
hemorrhage,  26 
symptoms,  26 
Bed-sores,  270,  276,  366 

treatment,  270,  276 
Bennett's  fracture,  252 
Bibliography,  471 
Bladder  (urinary),  rupture  of,  108 
symptoms,   108 
treatment,  operative,  109 
Blebs,  treatment  of,  359 
Borden  (W.  C),  quoted: 

infection  in  gunshot  wounds,  419 
treatment,  421 
Bradford  frame,  105,  312 

making  of,  313 
Brain  in  fractured  skull,  17 
compression  of,  18 
concussion  and   contusion  of, 

17 
laceration  of,  18 
symptoms,   18 
Bryant's    method    of    measurement 
after   fracture   of   neck   of   femur, 
265 
Buck's   extension   apparatus   (modi- 
fied), 288 
application  of,  291 
materials  required  for,  288 


475 


476 


INDKX 


Bullard,  Dr.  (Boston  City  Hospital), 
quoted:     results     of     fracture     of 

skull,  38 


Cabot's   posterior   wire   splint,    310, 
332,  364 
application,  310,  367 
covering,  365 
making,  365 

padding  of,  for  reception  of 
lower  extremity,  366 
Carpus,  246 
symptoms,  246 
treatment,   246 

metacarpus,  and  phalanges,  246 
Cauda    equina,    compression    of,    in 
fracture  of  spine,  77,  90 
lesion  of,  87 

treatment,  87,  93 
Clavicle,   110 
anatomy,    110 
operative  treatment,  120 

in  ununited  fractures,   120 
prognosis,   119 
symptoms,    111 

in  childhood,   112 
treatment  in  adults,  113 

modified  Sayre  dressing,  116 
recumbent,  113 
treatment  in  children,   117 
Codman,     Ernest    Amory:     Rontgen 
ray  and   its  relation  to   fractures, 
424 
CoUes'  fracture,  223 
anatomy,  223 
differential  diagnosis,  231 

contusion     of     bones     near 

wrist,  232 
dislocation    of    wrist    back- 
ward, 232 
fracture  of  shaft  of  one  or 
both    bones    low    down, 
233 
separation  of  lower  epiphy- 
sis of  radius,  235 
sprain  of  wrist,  231 
lesions  associated  with,  236 
operative   treatment   for  result- 
ing deformity,  245 
prognosis  and  result,  244 
"reversed,"   244 
symptoms,  226 
treatment,  236 

a  method  of  reduction,  236 
retentive  apparatus,  239 
application  of,  240,  241 
Coma,  30,  33 
alcoholic,  30 
from  apoplexy,  30 
from  hemorrhagic  internal  pachy- 
meningitis, 31 


Coma  from  opium-poisoning,  30 

in  uremia,  30 
Compression  of  brain,   18 

symptoms,  18 
Concussion  and  contusion  of  brain, 
17 
symptoms,   17 
Condyle  of  humerus: 
external,  173,  194 
treatment,  182 
internal,    172 
treatment,  182 
Contusion  of  bones  near  wrist,  232 
Coracoid  process  of  scapula,  129 
Coronoid  process  of  ulna,  198 

symptoms,  201 
Cystitis  after  fracture  of   spine,   81 
92 


Deformity  after  CoUes'  fracture,  245 
after  fracture  of  clavicle,  119 
of  leg,  354 

of  metacarpal  bones,  253,  257 
of  shaft  of  femur,  297 

backward  sagging  of  thigh, 

298 
eversion  of  foot,  297 
outward  bowing,  297 
from    separation    of    epiphysis    of 

humerus,  upper,   145 
in  CoUes'  fracture,  226 
anteroposterior,  226 

silver-fork  deformity,  227 
lateral,  227 

slight  deformity  only,  228,  230 
in    fracture    of    both    radius    and 
ulna,  192,  210 
of  shaft  of  radius,  195 
in  fractures  of  vertebrae,  76 
in  greenstick  fracture  of  bones  of 

forearm,  192 
in  Pott's  fracture,  385,  398 

reversed  Pott's  deformity,  386 
in  separation  of  lower  epiphysis  of 

radius,  197 
of  nose  from  fracture,  44,  47,  51 
from  syphilis,  46 
Dislocation  of  hip,  266 

of  humeral  head,   131,   146 
treatment,    146 
operative,   147 
of  radius  and  ulna  backward,  with 
or  without  fracture  of  coro- 
noid process  of  ulna,  169 
treatment,  187 
of  wrist,  backward,  232 
DoUinger's  method  of  application  of 
plaster  splint  in  ambulatory  treat- 
ment of  fracture's,  464 
Drainage  in  open  fracture  of  leg,  377 


IxNDEX 


47 


EccHYMOSis  in  fracture  of  leg,  355 
Edema,   causes  of,   after  fracture  of 
leK  or  tliigh,  384 
cere  lira  1,  21 
malignant,  321 
Elbow,  after-care  of  injuries,    188 

omission   of   splint,    or   reten- 
tive apparatus,  189 
method  of  examination,   162 
carrying  angle,    165 
head  of  radius,  163 
measurements,  1 65 
movements     at     elbow-joint, 

165 
palpation   of   the   three   bony 

points,  163 
summary  of  order  of  examina- 
tion, 166 
the  three  bony  points  of  the 
elbow  region,   163 
prognosis,   189 
traumatic  lesions  of,  168 

of  lower  end  of  humerus,   168 
of  radius  and  ulna,  168 
symptoms,   169 
treatment,  181 

acutely  flexed  position,  182,  187 
method  of  using,  182 
precautions  in  using,  184 
Elbow-joint,  treatment  of,  with  frac- 
ture of  shaft  of  humerus,   155 
EmboUsm,  383 
fat,  322 

symptoms,  323 
treatment,  323 
Emergency  method  of  putting  up  a 

fracture  of  the  thigh  or  hip,  283 
Emphysema    in    fracture    of    nasal 
bones,  46 
of  ribs,  95,  99 
of  superior  maxilla,  56 
Epicondyle,  internal,   172 

treatment,  182 
Epiphyses,   anatomical  facts  regard- 
ing the,  407 
acromion  process  of  scapula,  412 
date  of  appearance  of  ossification 
in  chief  epiphyses  of  long  bones 
(after  Poland),  408 
femur,  lower  epiphysis  of,  409 
humerus,  lower  epiphysis  of,  411 

upper  epiphysis  of,  409 
importance    of    exact    knowledge, 

408 
order  of  frequency  of  separation  of 

epiphyses  (after  Poland),  408 
radius,  lower  epiphysis  of,  410 
tubia,  lower  epiphysis  of,  412 
upper  epiphysis  of,  412 
Epiphvsis,  fracture  of,  radial,  lower, 
235 
separation  of  acromion,  121 


Epiphysis,  separation  of  femur,  lower 
epiphysis,  314,  410 
anatomy,  315,  410 
complications,  316 
diagnosis,  316 
prognosis,  318 
treatment,  318 
fat  embolism,  322 
operative     method     of 

reduction,  320 
reduction  by  manipula- 
tion  when   the   frag- 
ment is  displaced  for- 
ward, 319 
traumatic        gangrene, 
septicemia,       malig- 
nant edema,  321 
humerus,  132 

lower  epiphysis,  175 
diagnosis,  178 
treatment,    188 
upper  epiphysis,  132,  140,  146, 
409 
prognosis,   144 
treatment,  140 
radius,  195 

lower  epiphysis,  197,  235,  411 
treatment,  197,  209,  235 
tibia,  351 

lower  epiphysis,  356,  412 
upper  epiphysis,  351 
Ethmoid,  cribriform  plate  of,  28 
Extension  weights  after  fracture  of 
neck  of  fenmr,  271 
of  shaft  of  femur,  295 
Extravasation  of  urine,  108,  109 


Face,  bones  of,  44 
malar  bone,  52 
maxilla,  inferior,  59 

superior,  56 
nasal  bones,  44 
Feeding,    after   fracture   of   jaw,    by 
mouth,  70 
nasal,  58 
Femur,  260 

gunshot  fracture,  422 
mortality,  422 

comparative,     in     different 

wars,  423 
in  South  African  war,  424 
prognosis,  424 
symptoms,  422 
treatment,  423 
neck  of.     See  Hip. 
shaft  of,  280 

after-treatment     and     progress, 

301 
measurement,  282 

Dr.  Keen's  method,  283 


478 


INDEX 


Femur,  shaft  of,  symptoms,  282 
treatment,  283 

Buck's    extension    apparatus, 

288 
emergency  treatment,  283 
method  of  examination,  287 
transportation    of    a    patient, 
283 
in  childhood,  309 
symptoms,  309 
treatment,  309 

Bradford  frame,  312 
Cabot's  posterior  wire 
splint,  310 
prognosis,  304 
results,  305 

fractures  of  adult  life,   307 
of  childhood,  306 
of  old  age,  307 
subtrochanteric  fracture,  299 
symptoms,  299 
treatment,  299 
operative,  300 
supracondyloid  fracture,  300 
symptoms,  300 
treatment,  300 
Flat-foot,  traumatic,  404 

treatment,  404 

Foot,  bones  of,  400 

astragalus,  400 

and  OS  calcis,  open  fracture  of, 
404 
metatarsal  bones,  405 
OS  calcis,  401 
phalanges,  406 
Forearm,  bones  of: 

CoUes'  fracture,  223 
olecranon,  214 
radius  and  ulna,  192 
Fragments  of  bone  in  open  fractures, 
376 
slightly  fixed,  376 


Gangrene  of  leg,   after  fracture   of 
femur,  308 
of  lower  leg,  361 

treatment,   361 
from  separation  of  lower  epiph- 
ysis of  femur,  316,  321 
traumatic,  321,  361 
Greenstick  fracture  of  bones  of  fore- 
arm, 192 
treatment,  213 
of  clavicle,   112 
Gunshot  fractures  of  bone,  413 

comparison  of  old  and  modern 

bullet,  418 
explosive  effect  of  bullet,  415 
factors  upon  which  amount  of 
damage     to     bone     is     de- 
pendent, 413 


Gunshot  fractures  of  bone,  factors 
upon  which  amount 
of  damage  to  bone  is 
dependent,  resist- 
ance, 415 
revolution     of     bullet, 

414 
shape  of  bullet,  413 
velocity  of  bullet,  413 
prognosis  in 'fractures  of  femur 

424 
ricochet  bullet,  417 
the  modern  rifle,  413 
treatment,  419 

first  field  dressing,  419 
fracture  of  femur,  423 
infected  wounds,  421 
noninfected  wounds,  420 
operative,  421 
wounds  of  entrance  and  exit, 
417 
of    modern    projectiles    less 
grave,  419 


Head  injury,  cases  of,  39 

I.  Middle  meningeal  hemor- 
rhage with  fracture  of 
skull,  39 

II.  Open  depressed  fracture 
of  skull;  paralysis  of  one- 
half  of  body,  41 

III.  Middle  meningeal  hemor- 
rhage; fracture  of  skull,  43 

Heel,  care  of,  in  treatment  of  frac- 
ture of  leg,  366 
of  Pott's  fracture,  394 
Hematoma   of   cartilaginous   septum 
of  nose,  51 
of  scalp,  24  I 

HematomyeUa,  87 
Hemorrhage,  extradural,  19,  88 
sources  of,  20 
symptoms  of,  19 
in  fracture  of  base  of  skull,  26,  28 
of  humerus,   150 
of  leg,  360 
into  pharynx,  29 
into  spinal  cord,  86 

hematomyelia,  87 
middle   meningeal,    cases   of,    with 

fracture  of  skull,  39,,  43 
subconjunctival,  28,  29,  55 
Hip,  or  neck  of  femur,  260 
anatomy,  260 
fracture  in  adults,  260 
examination,  263 
impacted  and  unimpacted , 

261 
measurement,  264 

Bryant's  method,  265 
prognosis  and  result,  268 


IXDUX 


479 


liip,  fracture  in  adulls,  results  allir, 
268 
syin])toms,  261 
Ireatinent,  269 

after-care  of  the  simple 

traction  method,  271 

fixation  method,  272 

Thomas  hip-splint, 

273 

general  considerations, 

269 
operative       treatment, 

277 
treatment  of  the  frac- 
tured hip,  271 
fracture  in  childhood,  277 
immediate  result,  280 
late  restilt,  280 
symptoms,  280 
treatment,  280 
Hot-air  treatment,  245,  404 
Humerus,   125 

after-care,  143,  147 
anatomical  neck  of,  132,  146 
treatment,  140 

with  dislocation  of  upper  frag- 
ment, 146 
after-treatment  of  oper- 
ated cases,  147 
treatment,  146 
anatomy,    125 
diagnosis,  129 

examination  of  shoulder,  126 
prognosis  and  result,  144 
shaft  of,   147 

fracture  in  the  newborn,    158 
treatment,  158 
(transverse)    above    the    con- 
dyles, 173,  186 
treatment,  186 
malignant  disease,  162 
musculospiral  nerve  in  fracture 

of  the  humerus,  159 
prognosis,   157 
symptoms,   148 

treatment  of  fractures  with  con- 
siderable      displace- 
ment, 156 
after-care,   157 
operative,   156 
with   little   or  no   displace- 
ment, 151 
after-treatment,    156 
simple  dislocation  of  humeral  head, 

subcoracoid,   131 
surgical  neck  of,  fracture  of,  140, 1 46 
treatment,  140 
with    dislocation    of    upper 
fragment,   146 
after-treatment        of 
operated  cases,  147 
treatment,  146 


Humerus,   surgical  neck  of,   oblique 
fracture,  witii  great 
disj)laeement,  146 
treatment,  146 
operative,  146 


Ice-bags,  362 
Hium,  103 

Infection   in   fracture   of   metatarsal 
bones,  406 
of  nasal  bones,  46,  50,  51 
of  superior  maxilla,  57 
in  gunshot  fractures,  419,  420 

of  femur,  424 
in  open  fracture  of  leg,  375 


Keen's  method  of  measuring  lengths 

of  lower  extremities,  283 
Kocher's    classification    of    parts    of 
long    bones    injured    in    gunshot 
wounds,  415 
Krause,  quoted  :  advantages  of  ambu- 
latory treatment,  468 
table  containing  average  periods  of 
heaHng,  467 


La  Garde,  quoted :  wounds  of  modern 

projectiles,  418 
Lee-Metford    (EngUsh)    bullet,    size, 
418 
velocity,  418 
weight,  418 
Leg,  346 

anatomy,    346 

examination  of  fractured  leg,  351 
general  observations,  350 
Pott's  fracture,  384 
prognosis,  380 
results,   381 
refracture,  384 

thrombosis  and  embolism,  383 
symptoms,  353 
treatment,   356 
after-care,  379 

care  of  fracture  of  the  leg  after 
the    permanent    dressing    has 
been  applied,  377 
fractures    difficult    to    hold    re- 
duced, 370 
fractures  with  considerable  im- 
mediate swelling,  359 
permanent         dressing, 
364 
care  of  heel,  366 
temporarv         dressing, 
362 
in    fractures    with    little    or    no 
displacement  or  swelling,  357 


48o 


INDEX 


Leg,  treatment,  open  fractures,  374 
permanent  dressing,  374 
temporary  dressing,  374 
wound  of  soft  parts,  375 
Limitation    of    motion    after    CoUes' 
fracture,  244,  245 
after  fracture  of  bones  of  fore- 
arm, 212 
of  elbow,  190 
of  olecranon,  222 
of  patella,  340,  344 
of    scaphoid    bone    of    wrist, 
247,  249 
after  open  fracture  of  astragalus 

and  OS  calcis,  405 
after  separation  of  lower  epiph- 
ysis of  femur,  321 


MacCormac  (Sir  William),  quoted: 
treatment  of  gunshot  fracture   of 
femur,  422 
Makins  (George  Henry),  quoted :  gun- 
shot  wounds  in   South   African 
war,  416 
gunshot  fracture  of  femur,   422 

prognosis,  424 
treatment  by  amputation,  422 
Malar  bone,  52 

complications,   55 
examination,   52 
symptoms,  53 
treatment,  55 
Malignant  disease,  162 
Massachusetts      General       Hospital, 
cases    treated    at : 
results  after  fracture  of  femur, 
305 
of  hip,  268 
of  leg,  381 
of  patella,  341 
statistics    concerning    ambulatory 
treatment,   467 
Massage  after  fracture  of  astragalus, 
400 
of  bones  of  forearm,  210 
of  clavicle,  119 
of  elbow,  189 
of  humerus,   144,   147,   157 
of  leg,  378 

of  metacarpal  bones,  257 
of  patella,  331,  336 

with  operative  treatment,  345 
of  ribs,  99 
of  scapula,   124 
of  shaft  of  femur,  302 
after  Pott's  fracture,  397 
after  separation  of  lower  epiphyses 

of  femur,   321 
in  CoUes'  fracture,  242,  245 
in  fracture  of  carpus,  248 
of  olecranon,   220 


Massage  in  fracture  of  os  calcis,  404 
Materials  for  ordinary  care  of  closed 

fractures,   469 
Mauser  bullet,  revolution  of,  415 
size,  418 
velocity,   418 
weight,  418 
Maxilla,  inferior,  59 
examination,  60 
fracture  of  body  of  jaw,  62 

of    ramus    upon    same    or 
opposite  sides  of  inferior 
maxilla,  70 
of  coronoid  and  articular  pro- 
cesses, 71 
of    ramus,   just  behind   molar 
teeth,  69 
symptoms,  60 

treatment,  61,  62,  69,  70,  71 
superior,  56 
after-care,  58 
diagnosis,   56 
treatment,  57 
Measurement  in  CoUes'  fracture,  225 
in  dislocation  of  humeral  head,  131 
in  fracture  of  elbow,   165 
of  external  condyle,   173 
of  humerus,  129,  150 
of  leg,  353 

of  neck  of  femur,  264 
of  shaft  of  femur,  282,  295,  301 
in  Pott's  fracture,  386 
in  T-fracture  into  elbow- joint,  180 
Metacarpal  bones,  249 

differential  diagnosis,  253 
symptoms,  249 
treatment,  253 
Metatarsal  bones,  405 
complications,  406 
symptoms,   405 
treatment,   406 
Morphin,  use  of,  369 
Musculospiral    nerve    in    fracture    of 
humerus,  159 
prognosis,   160 
symptoms  of  injury,    159 
compression,    160 
contusion,   159 
treatment,    1 60 
operative,   160 


NancrEde,  quoted  :  gunshot  wounds 

of  bones,  417,  421 
Nasal  bones,  44 

anatomy,   44 

complications,  46 

prognosis,  51 

symptoms,  46 

treatment,  49 
septum  in  fracture  of  nose,  47 

dislocation,  47 


INDHX 


481 


Nasal  septum,  lesions,  48 

hori/.oiual  fractures,  48 
sigmoid  deviations,  48 
treatment,  49 
vertical  fractures,  48 
Necrosis  after   fracture   of   humerus, 
with  dislocation  of  upjjer  frag- 
ment,  147 
of  leg,  38 1 
of  lower  jaw  ,  dl 
of  metatarsal  bones,  406 
of  upi)er  jaw,  57 
after  separation  of  lower  epiphysis 

of  femur,  316,  318 
in  open  fractures  of  the  phalanges, 
259 
Nerves,  lesions  of,  28,  29 

after  separation  of  lower  epiph- 
ysis of  femur,  316 
in  fracture  of    base  of    skull,  28 
29 
of  humerus,   159 
of  the  vertebrae,  74 
spinal,  anatomy,  74 
Nonunion  of  fracture  of  clavicle,  120 
operative  treatment,   120 
of  hip,  268 
of  leg,  380 
of  fractures,  212 
causes,  213 
treatment,   213 

operative,  213,  222 
Nose,  deformity  of,  from  fracture  44 
47,   51 
from  syphilis,  46 
Nussbaum,  von,   quoted:  first  dress- 
ing of  gunshot   wounds,   419 


Olecranon,  214 
after-care,  220 
anatomy,  214 
process,   171 

summary  of  treatment,  222 
symptoms,  214 
treatment,   217 

if  fracture  is  open,  220 
operative,  219 
Orbital  plate,  27 
Os  calcis,  401 

open  fracture,  404 

treatment,  operative,  405 
results,  404 

flat-foot,  404 
symptoms,  402 
treatment,  403 


Paralysis  in  fracture  of  skull,  18,  34 
in  fractures  of  vertebrae,  76 
cervicodorsal  region,  80 
dorsal,  79 


Paralysis   in    fractures   of   vertebrae, 
last   dorsal  and   lumbar,   77 
midccrvical  region,  81 
in  lesions  of  sjjinal  cord,  82 
ol)stelrical,    159 

of    muscidospiral    nerve,    in    frac- 
ture of  humerus,  148,  159 
Passive  motion  after  Colics'  fracture 
242,  245 
after  fracture  of  astragalus,  400 
of  bones  of  the  forearm,  210 
of  carpus,  248 
of  clavicle,    1  19 
of  ell)ovv,   189 
of  femur  (shaft),  302,  303 
of  humerus,  147,   157 
of  leg,  378 
of  olecranon,  221 
after  Pott's  fracture,  397 
after  separation  of  lower  epij)h- 

ysis  of  femur,  321 
in     fracture     of     patella,     with 
operative  treatment,   345 
Patella,  324 
anatomy,    324 
open  fracture,  338 
treatment,  338 
operative    interference    in    recent 
closed  fractures,   342 
conditions  suitable,  344 
danger  of  sepsis,  343 
indications,  345 
method    of    operation, 

345 
proper  time  to  operate 

344 
restoration  of  function 
of      joint      following 
operative  treatment, 
345 
prognosis,  339 
results,  341 
symptoms,  328 
treatment,  329 

limitation  and  removal  of  effu- 
sion, 329 
maintenance  of  reduction   until 

union  is  satisfactory,  334 
reduction  of  fragments,  332 
restoration  of  function  of  joint 

336 
summary   of    treatment    by    ex- 
pectant or  nonoperative  meth- 
od, 337 
Pelvis,  103 

complications,   106 

rupture  of  urethra,  107 

of  urinary  bladder,  108 
visceral  lesions,  106 
examination,    103 
prognosis,   109 
treatment,  105 


482 


IND^X 


Phalanges,  257,  406 
of  the  foot,  406 

treatment,  406 
of  the  hand,  257 
open  fracture,  259 

operative  treatment,  259 
symptoms,  257 
treatment,  257 
Plaster-of -Paris  bandage  after  separa- 
tion   of    lower    epiphysis    of 
femur,  321 
in  fracture  of  leg,  357,  359 
employment  of,  441 

application  to  patient,  458 
dextrin  bandage,  460 
making  of  bandages,  441 
removal  of  the  plaster  splint,  460 
rolling  the  plaster,  441 
shoulder  cap,  141 
splint,  traction,  early  use,  462 
method  of  application,  372 
Pleurisy  in  fracture  of  ribs,  95 
Pneumonia,  asthenic  hypostatic,  271 
Poland,  John  (his  "Traumatic  Sepa- 
ration of  the  Epiphyses"  quoted), 
408 
Pott's  fracture,  384 
anatomy,   384 

lesions  which  may  be  present,  384 
open  fracture,  398 

indications  for  amputation, 
398 
operative  treatment  of  old  frac- 
tures, 398 
prognosis  and  results,  398 
symptoms,  385 
treatment,   386 

care,  after  permanent  dressing 

is  apphed,  396 
Dupuytren  splint,  387 
lateral  and  posterior  plaster- 
of-Paris    splints    (Stimson's 
splint),  394 
posterior     wire     splint     with 

curved  foot-piece,  393 
temporary  dressing,  387 
Pubic  portion  of  ring  of  pelvis,  105 


Radio-ulnar     joint,     inferior,     in- 
volvement of,   in  CoUes'   fracture, 
244 
Radius  and  ulna,  dislocation  of,  169, 
194 
fracture  of,  192 

of   coronoid   process   of   ulna, 

198 
of  neck  and  head   of  radius, 
194 
symptoms,   194 
treatment,  188,  208 
of  neck  or  head  of,  172,  194 


Radius  and  ulna,  fracture  of  shaft  of 
radius,  195' 
symptoms,   195 
treatment,  208 
operative,  209 
of  shaft  of  ulna,  197 
incomplete  or  greenstick  frac- 
ture, 192 
prognosis  and  result  of  treat- 
ment, 211 
separation  of  lower  epiphysis 

of  radius,  195 
symptoms,  192 
treatment,  201 

of  open  fractures,  211 
subluxation  of  head  of  radius,  169, 
194 
Reflexes  in  fractures  of  the  vertebrae, 
76 
dorsal,  80 
Refracture    of    bones    of    the    lower 

extremity,  384 
Retention  and  incontinence,  in  frac- 
tures of  the  vertebrae,  77 
Ribs,  94 

anatomy,  94 
complications,  95,  99 
symptoms,  94 
treatment,  95 

after-treatment,  99 
operative,  99 
Roe's  elevator,  49 

Rontgen  ray  and  its  relation  to  frac- 
tures, 425 
assistance  of,  in  diagnosis,  432 
in  examination,  432 
in     knowledge     of     pathology 
and  treatment  of  fractures, 
431 
Crooke's  tube,  426 
effects  of  X-rays,  extent  of,  427 
accuracy  and  inaccuracy  of 

pictures,  431 
distortion  of  shadows,  427, 
434 
fluoroscope,  426,  434 
forms   of  fracture   in  which  X- 
ray  gives  great  assistance, 
433 
elbow,  434 
femur,  upper  extremity  of, 

435 
foot,  bones  of,  436 
patella,  435 
shoulder-joint,  433 
wrist,  435 
medicolegal  relations  of  X-rays; 
conclusions    expressing   views 
of  American  Surgical  Associa- 
tion adopted  in  May,  1900,  438 
use  of,  as  a  method  of  record  in 
rare  fractures,  433 


INDEX 


483 


Rontgen  ray,  use  of,  in  demonstrat- 
ing to  students,  432 
X-ray  burns  and  dermatitis,  436 
X-ra)^  picture  and  photograph, 
comi)arison  of,  426 
Rontgen  raj-s  in  Colles'  fracture,  231, 
232,  233,  238,  435 
in  fracture  of  astragahis,  400 
of  carpus,  246,  435 
of   coronoid   process   of   idna, 

201 
of  elbow,  181,  434 
of  humerus,  130,  434 
of  neck  and  head  of  radius,  194 
of  neck  of  femur,  267 
in  gunshot  fractures,  420 
in  knowledge  of  epiphyses,  407, 
435 


Sand-bags,  271,  293 
Sayre    dressing    (modified)    in    frac- 
ture of  clavicle,   116,   118 
Scaphoid  bone  of  wrist,  246 

diagnosis,  246 
Scapula,    121 

acromial  process,  121 
body  of  scapula,  121 
neck  of  scapula,  121 
treatment  in  general,  123 
Sepsis.     See  Injection. 
Septicemia,  321 
Shock  after  fracture  of  jaw,  58 

of  neck  of  femur  in  the  aged,  268 
of  pelvis,    107 
of  shaft  of  femur,  308 
of  the  vertebrjE,  76,  93 
after   gunshot   fracture   of   femur, 

422 
after  rupture  of  urinary  bladder, 

108 
after  separation  of  lower  epiphysis 
of  femur,  316 
Shortening  of  the  leg  after  separation 
of  lower  epiphysis   of  femur, 
318 
in  fracture  of  leg,  353,  380 
of  neck   of  femur,    262,    265, 
268,  277,  278 
correction,  275 
of  shaft  of  femur,  282,  305 
prevention,  295 
Skull,   17,  22 

compression  of  brain,  18 
concussion  and  contusion  of  brain, 

17 
diagnosis,  33 

examination  of  patient,  31 
general  condition,  32 
local  condition,  32 
fracture  of  base,  26,  59 
of  vault,  24 


Skull,  general  observations,  33 
hemorrhage,  extradural,  19 
laceration  of  brain,  18 
later  results  of  fracture,  38 
operative  interference,  36 
prognosis,  38 
subarachnoid      serous     exudation 

(cerebral  edema),  21 
treatment,  34 
ear,  35 
mouth,  36 
nose,  35 
scalp,  35 
unconscicnisness      resulting      from 
other  than  surgical  causes,  30 
Slings  for  Colles'  fracture,  240 
for  fractured  humerus,  155 
Smith  anterior  wire  splint,  369 
Spinal  cord,  anatomy,  72 
lesions  of,  73,  82,  93 
how  to  localize,  73 
transverse   and    partial,    82 

symptoms,  82 
treatment,  85,  93 
operative,  85,  87,  93 
Spine,  injury  to,  examination,   76 
Sphnts  for  Colles'  fracture,  239,  244 
for  fracture  of  astragalus,  400 
of  bones  of  forearm,   after-care 
of  wooden  and  tin  splints, 
207 
in  greenstick  fractures,  214 
internal  right  angle  (of  tin) , 

206,  209 
palmar  and  dorsal  (of  wood) , 
205,  208 
method  of  application, 
206 
plaster-of-Paris,  202,  208 
after-care,  203 
precautions  in  using,  202 
of  carpus,  248 

of   elbow,   internal   right   angle, 
186,   187 
appHcation  of,  187 
right-angle    internal    angular, 
181 
of  humerus,  coaptation,  156 
internal  angular,  156 
plaster-of-Paris,  157 
application  of,  157 
of  jaw,  buckle  and  strap,  69 
chin-piece,  64 
dental,  57,  62 

making  of,  67 
temporary,  58 
of  leg,  pillow  and  side,  362 
plaster-of-Paris,  357,  363,  368, 

372,  377 
posterior  wire  and  side,   364, 
377 
of  metacarpal  bones,  255 


484 


INDEX 


Splints   for   fracture    of    metatarsal 
bones,  406 
of     olecranon,     internal     right- 
angle,  218 
long  internal,  218 
of  OS  calcis,  404 
of  patella,  332 

in  open  fracture,  336 
plaster-of-Paris,  335 
method  of  making,  335 
of  phalanges  of  foot,  406 

of  hand,  258 
of   shaft   of   femur,    Buck's   ex- 
tension apparatus,   289 
emergency,  283 

application,  283 
permanent  dressing,  286 
for    Pott's    fracture,     Dupuytren, 
387 
application  of,  391 
defect  of,  393 
lateral  and  posterior  plaster- 
of-Paris   (Stimson's  splint), 
394 
posterior    wire,    with    curved 
foot-piece,  393 
application  of,  393 
nasal,  50 
Cobb's,  50 
Coolidge's,  50 
tin,  50 
Sponge    compresses    in    fracture    of 

patella,  330 
Sprain  of  wrist,  231 
Sternum,  100 

complications,   101 
diagnosis,   101 
treatment,  101 
operative,   102 
Stimson's  splint,  394 
Subarachnoid  serous  exudation,  21 
Subluxation  of  head  of  radius,    169, 

194 
Suturing    fractured    bone,    humerus, 
156 
jaw,  59 
leg,  373,  376 

radius  and  ulna,  209,  211 
Synovitis  in  fracture  of  patella,  329 
treatment  by  aspiration,  334 
by  massage,  331 


Taylor  hip  traction  splint,  303 
application  of,  303 
use  of,  in  ambulatory  treat- 
ment of  fracture  of  thigh, 
303,  466,  468 
steel  back-brace,  102 
Teeth,  after  fracture  of  jaw,  57,  60,  61 
Temperature,   pulse,  and   respiration 
in  fracture  of  skull,  18,  34,  38 


Temporal  bone,   fracture  of  petrous 

portion  of,  28 
Tenotomy  of  tendo  Achillis,  372 
Tetanus  after  a  fracture,  223 

treatment,   223 
T-fracture  into  elbow-joint,  180 

treatment,  182 
Thomas  hip-splint,  273 
application,  275 
description,  273 
knee-splint,  462 
Thomson      (Prof.      Elihu),     quoted: 
effects  of  X-rays   on    the  tissues; 
a  personal  experiment,  437 
Three  bony  points  of  elbow  region,  163 
Thrombosis,  383 
Tibia,  oblique  fracture  of,  370 
Trephining  in  fracture  of  vertebrae,  89 
T-splint,    106,  271,  289 

Ulna,  shaft  of,  symptoms,   197 

treatment,  209 
Union  of  bones,  time  necessary  for, 
after  separation  of  lower 
epiphysis  of  femur,  321 
in  Colles'  fracture,  243,  244 
in  fracture  of  astragalus,  401 
of  bones  of  forearm,  209 
of  elbow,  189 
of  humerus,  144 

in  the  new-born,  159 
shaft,  with  considerable 
displacement,  157 
with  little  or  no  dis- 
placement,   156 
of  leg,  378 
of  metatarsals,  405 
of  olecranon,  222 
of  OS  calcis,  404 
of  patella,  334 

with     operative     treat- 
ment, 345 
of  phalanges,  259 
of  shaft  of  femur,  301 
in     greenstick    fracture    of 

forearm,  214 
in  refractures,  384 
Ununited  fractures.     See  N onuniofi. 
Urethra,    injury    to,    in    fracture    of 
pubic  bone,  105 
rupture  of,  in  fracture  of  pelvis,  107 
extravasation,   108 
symptoms,    107 
treatment,  107 

Vault  of  skull,  24 
Vertebrae,  fractures  of,   72 

anatomy,    72 

dislocations  of,  73 

examination   of   an   injury  to   the 
spine,  76 


INDEX 


485 


Vertebra2, general  syiii])l(inisc(inHn(m 
to  fractures  of  tlie,  76 
gunshot  fractures,  9^ 

treatment,  9^ 
lesions  following  injury  to  definite 

vertebrae;  with  table,  75 
])rognosis,  81 

symptoms  of  fracture   of    different 
regions    of    the    spine,    tlie 
cord  being  involved,   77 
injuries  to  cer\'icodorsal  region, 
opposite  cervical  enlarge- 
ment of  spinal  cord,  80 
to  the  dorsal  vertebrae,  79 
to    the    first    two    cervical 

vertebrae,  81 
to   last   dorsal   and   lumbar 
vertebrae,   77 
operation,  time  for, 

79 
prognosis,  77 


\'ertebrae,     symptoms    of     fracture, 
injuries   to    midcervical    region, 
80 
treatment,   81 

plaster-of-Paris  jacket,   90 
method  of  applying,  91 
summary,  93 
Vertical    susj^ension     in     fracture    of 

thigh  in  childhood,  312 
Visceral  lesions  in  fractures  of  ])elvis, 

106 
V-shaped  pad,  in  fracture  of  Inimerus, 
141,   153 


Wiring  fractured  bones  of  the  jaw, 
59,  62,  71 
of  the  pelvis,   106 
Wounds  of  open  fractures,  cleansing, 

375,  399 


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